Use of high-frequency ultrasound in the assessment of injectable dermal fillers

Complications of toxins and fillers in facial aesthetics

Dermal filler and botulinum toxin injections are among the most performed non-invasive procedures for rejuvenation and contouring, internationally. Although most dermal fillers and approved botulinum toxins are well tolerated with a high safety profile, adverse events and/or complications can happen. Injection-related sequelae and side effects are usually rare, mild, transient, and self-limiting in nature. However, devastating and life-changing complications, such as intravascular occlusion, skin necrosis, permanent visual impairment, and stroke, have been reported. Risk reduction measures include an in-depth knowledge of anatomy, physiology, and pharmacology, correct patient selection, correct identification of clinical indications, and, fundamentally, the importance of appropriate skill and training. In this paper, some of the complications are discussed and advice on how to minimise adverse events and complications from these injectables is provided.

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.

Elucidations on the Performance and Reversibility of Treatment with Hyaluronic Acid Based Dermal Fillers: In vivo and in vitro Approaches

PURPOSE

The aim of this study was to investigate the performance and the reversibility of different classes of Hyaluronic Acid (HA) dermal fillers. We analysed 4 HA based fillers, belonging to 3 different chemical classes of products, commonly used in the field of wrinkles correction: linear HA 8 mg/mL (Viscoderm 0.8), thermically stabilized hybrid complexes of high and low molecular weight HA molecules at a concentration of 32 mg/mL and 45 mg/mL respectively (Profhilo and Profhilo Structura) and cross-linked HA 25 mg/mL (Aliaxin GP).

METHODS

The products were tested by a well-established animal model. The generated implants were analyzed through High-Frequency Ultrasound technology. Then, reversibility of the treatment was evaluated by enzymatic degradation kinetics studies, characterised by a combined approach of Carbazole assay and HP-SEC/TDA method.

RESULTS

Implants generated by linear HA 8 mg/mL remained detectable by ultrasound acquisition for 4 weeks, whereas those generated by injection of HA hybrid complex 32 mg/mL were detectable for 10 weeks. HA hybrid complex 45 mg/mL and cross-linked HA 25 mg/mL were detectable for 29 and at least 33 weeks, respectively. Enzymatic degradation kinetics studies demonstrated that the HA content in HA hybrid complex 45 mg/mL was almost completely depolymerized and homogeneous after 3 h of treatment. For cross-linked HA 25 mg/mL, 24 h of incubation are needed to obtain the same degree of depolymerization.

CONCLUSION

The study confirmed the ability of the experimental model to predict the behaviour of HA based dermal fillers in vivo and showed the innovative aspects of HA hybrid complex 45 mg/mL, that combines the high-safety profile, in terms of reversibility of the treatment, of the linear HA-based products with the durability of a high degree cross-linked gels, paving the way to the chance to be used for a wide range of applications in the field of aesthetic medicine.

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.

The Role of High Resolution Ultrasonography in Elucidating Features of the Breast Implants in Asymptomatic Patients After Implant-based Augmentation Mammaplasty

BACKGROUND

We conducted this study to describe the feasibility of high-resolution ultrasound (HRUS) in characterizing a breast implant in patients receiving an implant-based augmentation mammaplasty.

METHODS

The current study was conducted in a total of 612 patients (n =6 12) receiving an implant-based augmentation mammaplasty at other hospitals between August 31, 2017 and August 31, 2020. Of these, 136 patients (n = 136; 272 breasts) receiving reoperation were included in the current study. We compared between the patients' subjective awareness of a breast implant and its HRUS findings and an agreement between HRUS findings of a breast implant and its findings at reoperation.

RESULTS

The proportion of the patients receiving a silicone gel-filled breast implant was increased from 65.44% (89/136) to 81.61% (111/136) on HRUS. Moreover, HRUS was effective in identifying a manufacturer of the device.

CONCLUSIONS

In conclusion, our results indicate that HRUS is feasible in characterizing a breast implant in patients receiving an implant-based augmentation mammaplasty. But further prospective, large-scale studies are warranted to corroborate our results.

LEVEL OF EVIDENCE V

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 .

Practical applications of ultrasound in dermatology

Ultrasound has evolved in dermatology from an experimental phase to a daily practice imaging technique. Its several advantages include its safety, good balance between penetration and resolution, high definition, and the detection of blood flow in real time. Its applications are growing and include the support of the diagnosis and extent in all axes, including depth, vascularity patterns, staging, and follow up of multiple cutaneous diseases-benign cutaneous tumors, vascular anomalies, nail lesions, skin cancer, inflammatory cutaneous diseases, and aesthetics complications.

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.

Characterization of skin aging through high-frequency ultrasound imaging as a technique for evaluating the effectiveness of anti-aging products and procedures: A review

INTRODUCTION

High-frequency ultrasound skin imaging analysis (HFUS) is a non-invasive technique that allows a unique approach to the analysis of skin aging, as well as in evaluating the effectiveness of dermatological and cosmetic products, especially for skin rejuvenation.

OBJECTIVE

To describe the impact of skin aging and different anti-aging strategies from the perspective of high-frequency ultrasound.

METHODS

A bibliographic survey was carried out, selecting relevant articles that evaluated the characterization of the skin features from different points of view such as gender (male and female), age (young skin and mature skin), and ethnicity, in addition to individual variations between body regions and daily variations.

RESULTS

Some studies also evaluated the impact of cosmetic treatments and esthetic procedures in the skin. Parameters such as dermal thickness, echogenicity, skin texture, and subepidermal low-echogenic band (SLEB) were analyzed. It can be concluded that there is a trend, although not unanimous in the consequences of aging on the skin, being different between men and women, plus the individual nuances resulted from each one's lifestyle and exposure to the sun.

CONCLUSION

As for the technique, it is concluded that high-frequency ultrasound is an important evaluative alternative for dermatological studies and the effectiveness of anti-aging products and treatments.

Ultrasound patterns of different dermal filler materials used in aesthetics

Background Hyaluronic acid (HA) injection procedures has experienced an unprecedented increase. Aims To assess and determine, by using ultrasound examinations, the patterns corresponding to different dermal fillers. Patients/Methods Observational and retrospective bicenter study conducted on patients who underwent previous aesthetic treatments with dermal fillers. Ultrasound examinations were performed, at each study center, by one experienced observer. Results Sixty patients were included in the analysis. Among them, 48 patients showed a well-defined ultrasound pattern, while 12 exhibited a mixed one. According to ultrasound images, 4 different patterns were identified: [1] Heterogeneous, characterized by alternating hyperechoic and anechoic areas, which are visualized in the tissue in a heterogeneous way. This pattern is associated with healthy skin/subcutaneous cellular tissue and with fully integrated HA fillers. [2] Fine grain snowfall, characterized by alternating hyperechoic imaging, with posterior echogenic shadows. It is typical of liquid injectable silicone. [3] Coarse grain snowfall, characterized by hyperechoic images distributed all over the tissue. This is typical of calcium hydroxyapatite and polymethyl methacrylate-based fillers. [4] Globular, typical "cystic" imaging, with anechoic images indicative of liquid semi-liquid content. This pattern is characteristic of polyalkylamides and polyacrylamides, and HA-based fillers immediately after their injection. The presence of "mixed" patterns is mainly due to different aesthetic procedures performed at different times. Conclusions Ultrasound imaging may be a valuable tool for assessing the nature of former dermal filler procedures in daily practice. The identification of these patterns will allow specialists to choose the best therapeutic approach in patients who underwent previous aesthetictreatments.

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

Objective 18-month Comparison of the Tolerability of 2 Dermal Fillers Formulated with Tri-Hyal Technology

Supplemental Digital Content is available in the text.

Background:

The first phase of this study showed that ART FILLER Universal filler (AFU; FILORGA Laboratories) and ART FILLER Fine lines (AFFL) were non-inferior to JUVÉDERM Ultra 3 (Allergan) and FIRST LINES PureSense (Teoxane), respectively. The clinical benefits of AFU and AFFL on nasolabial folds and crow’s feet persisted until at least Day 180. This article reports results from an open-label extension phase that assessed the tolerability and efficacy of AFU and AFFL for up to 18 months based on clinical evaluation and ultrasound high-frequency imaging.

Methods:

Eligible subjects were enrolled at D180 and assessed on D270, D360, and D540. The primary outcome measured was local tolerability. Secondary outcomes measured included: proportion of subjects in whom the severity of nasolabial folds and crow’s feet remained at least 1 point below the baseline measurement (Lemperle scale); general safety; Global Aesthetic Improvement Scale scores by subjects and investigators; wrinkle volumes; and skin thickness by high-frequency ultrasound.

Results:

Adverse events were consistent with the product information and the initial study. No serious adverse events were recorded. In exploratory analyses, wrinkle correction with AFU and AFFL is sustained for at least 18 months: 48.4% and 98.3% of subjects respectively still showed at least a 1-point decrease in the mean Lemperle score compared with the baseline. The benefits were sustained irrespective of whether subjects received additional injections. Modifications in wrinkle volume and skin thickness at D540 were statistically significant compared with the baseline.

Conclusion:

AFU and AFFL were well tolerated and, in exploratory analyses, showed a sustained efficacy for at least 18 months.

Ultrasound detection of cosmic filler injection of lips in camel beauty pageants: first report in veterinary medicine

This study was carried out in Saudi Arabia during the events of the 4th King Abdulaziz Camel Festival, Saudi Arabia. It was designed to describe the most frequent locations of injected cosmetic fillers in the head region as well as the ultrasound features of the injected material. Apparently healthy camels (Camelus dromedarius) (n = 11,626) were thoroughly examined for injection of cosmetic fillers in the head region. In parallel, 30 non-injected camels were used as controls. The lips of camels suspected of having been injected with fillers were subjected to high-resolution ultrasound examination. Of the 11,626 camels, 58 were found to have been injected with cosmetic fillers, 45 in the upper lip and 13 in both the upper and lower lip. None of the injected camels had a history of recent illness. In addition, in all the injected camels, no dermal lip lesions were seen by the naked eye. Swelling of the upper and/or lower lips was visually inspected and palpated by hand in 52 of the camels. Drooping and swinging of the injected lips were observed in all injected camels. Hardness was detected in the tip of the upper lips of 26 of the injected camels and multiple hard nodules were palpated in the injected lips of 44 camels. Swelling of the edges of the upper and lower lips was detected in 41 of the injected camels. Ultrasonographic features of the injected lips are described in detail. Blood samples were collected from both groups. In none of the injected camels did the hemato-biochemical profiles differ significantly than the control group. In conclusion, results clearly indicate the usefulness and convenience of ultrasound as a diagnostic tool to locate the presence of injected fillers and to help monitor the extension and complications of the deposits.

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.

Long-Term Follow-Up of Longevity and Diffusion Pattern of Hyaluronic Acid in Nasolabial Fold Correction through High-Frequency Ultrasound

BACKGROUND

Injectable hyaluronic acid fillers have been widely applied in the clinical treatment of facial wrinkles. However, further information and clinical evidence concerning dermal changes and hyaluronic acid filler longevity after injection and diffusion pattern are limited.

METHODS

The authors evaluated the longevity and diffusion pattern of two hyaluronic acid fillers generated by different cross-linking technologies used in the treatment of nasolabial folds using high-frequency ultrasound. Forty-one subjects were treated with Restylane 2 and the remaining 41 were treated with Dermalax DEEP. Wrinkle severity rating scale score and high-frequency ultrasound evaluation of nasolabial folds were performed before and after the injection of hyaluronic acid filler. The ultrasound images were acquired and analyzed to determine dermal thickness and the shape and distribution of hyaluronic acid filler.

RESULTS

At 2 and 24 weeks from baseline, increased dermal thickness induced by hyaluronic acid filler treatment was not significantly different between groups. At 48 weeks after injection, increased dermal thicknesses of the Restylane 2 group (0.14 ± 0.12 mm) were much lower than those of the Dermalax DEEP group (0.20 ± 0.13 mm). Ultrasound examination revealed that hyaluronic acid materials form well-demarcated and hypoechogenic areas. Restylane 2 tended to form a more diffuse pattern, with multiple smaller bubbles, whereas Dermalax DEEP developed into a more localized configuration, with larger clumps.

CONCLUSIONS

This study is the first long-term assessment of nasolabial fold correction that reveals the performance of different hyaluronic acid materials in vivo and validates high-frequency ultrasound as a simple and rapid modality. Hyaluronic acid fillers generated by different cross-linking technologies display differential diffusion patterns in skin tissues.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

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.

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 and Infrared-Based Imaging Modalities for Diagnosis and Management of Cutaneous Diseases

Non-invasive bedside imaging tools are becoming more prevalent for assessing cutaneous lesions. Ultrasound used at specific frequencies allows us to assess margins of lesions to minimize the extent of the biopsy that is performed and improve cosmetic outcomes. Vascularity, seen on Doppler ultrasound and contrast-enhanced ultrasound, and stiffness, assessed on tissue elastography, can help differentiate between benign and malignant lesions for clinicians to be more judicious in deciding whether to biopsy. Moreover, research has shown the efficacy in using ultrasound in monitoring flares of hidradenitis suppurativa, a disease affecting apocrine gland-rich areas of the body, for which the current gold standard involves examining and scoring inflammatory lesions with the naked eye. Infrared-based modalities have also been on the uptrend to aid in clinical decision-making regarding suspiciousness of lesions. Reflectance confocal microscopy has lateral resolution that is comparable to histopathology and it has been shown to be an appropriate adjunctive tool to dermoscopy, specifically when evaluating melanomas. Optical coherence tomography has utility in determining lesion thickness because of its depth penetration, and spectrophotometric intracutaneous analysis is becoming more popular as a tool that can be used by general practitioners to know when to refer to dermatology regarding worrisome pigmented lesions. Strides have been made to incorporate electrical impedance spectroscopy alongside dermoscopy in decision-making regarding excision, although the evidence for its use in the clincial setting remains inconclusive. This paper reviews the efficacy and drawbacks of these techniques in the field of dermatology and suggests future directions.

Preventing the Complications Associated with the Use of Dermal Fillers in Facial Aesthetic Procedures: An Expert Group Consensus Report

Background

The use of dermal fillers in minimally invasive facial aesthetic procedures has become increasingly popular of late, yet as the indications and the number of procedures performed increase, the number of complications is also likely to increase. Paying special attention to specific patient characteristics and to the technique used can do much to avoid these complications. Indeed, a well-trained physician can also minimize the impact of such problems when they do occur.

Methods

A multidisciplinary group of experts in aesthetic treatments reviewed the main factors associated with the complications that arise when using dermal fillers. A search of English, French and Spanish language articles in PubMed was performed using the terms “complications” OR “soft filler complications” OR “injectable complications” AND “dermal fillers”. An initial document was drafted that reflected the complications identified and recommendations as to how they should be handled. This document was then reviewed and modified by the expert panel, until a final text was agreed upon and validated.

Results

The panel addressed consensus recommendations about the preparation, the procedure and the post-procedural care. The panel considered it crucial to obtain an accurate medical history to prevent potential complications. An additional clinical assessment, including standardized photography, is also crucial to evaluate the outcomes and prevent potential complications. Furthermore, the state of the operating theatre, the patient’s health status and the preparation of the skin are critical to prevent superficial soft tissue infections. Finally, selecting the appropriate technique, based on the physician’s experience, as well as the characteristics of the patient and filler, helps to ensure successful outcomes and limits the complications.

Conclusions

This consensus document provides key elements to help clinicians who are starting to use dermal fillers to employ standard procedures and to understand how best to prevent potential complications of the treatment.

Level of Evidence V

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.

High frequency ultrasound with color Doppler in dermatology

Ultrasonography is a method of imaging that classically is used in dermatology to study changes in the hypoderma, as nodules and infectious and inflammatory processes. The introduction of high frequency and resolution equipments enabled the observation of superficial structures, allowing differentiation between skin layers and providing details for the analysis of the skin and its appendages. This paper aims to review the basic principles of high frequency ultrasound and its applications in different areas of dermatology.

Identification and Complications of Cosmetic Fillers: Sonography First

Cosmetic fillers are frequently used these days for enhancing beauty and to treat wrinkles or sagging skin. However, information on the history of injections may be difficult to obtain, and there is a growing number of reports on complications with these agents. In contrast to other imaging techniques, sonography has been successfully used for detecting and identifying common types of cosmetic fillers and has become the first-line imaging modality to deal with these exogenous components.

Evaluation of a skin barrier cream for managing IAD in elderly patients using high-frequency ultrasound

Incontinence-associated dermatitis (IAD) is a defined pathological entity and presents a significant burden for patients and health-care systems. The main objective of this evaluation was to test the efficacy and safety of a skin barrier cream in the management of uncomplicated IAD in elderly patients. Ten incontinent patients with mobility problems that presented with signs of IAD were included in the evaluation. The evaluation took place during a 2-week period. The product's efficacy was objectively evaluated in each patient with high-frequency ultrasound scans taken from the irritated skin compared with an ultrasound scan taken from normal adjacent (control) skin. Data analysis showed a statistical significance in favour of the capacity of the product to help reduce inflammatory signs. Photographic follow-up allowed correlation of ultrasound findings and clinical signs. The product was effective in treating the skin irritation and preventing further skin breakdown. There were no adverse events during the evaluation.

Hyaluronic acid gel distribution pattern in periocular area with high-resolution ultrasound imaging

BACKGROUND

High-resolution ultrasound (HRUS) is a useful tool in defining anatomic and dynamic soft tissue relationships in the periocular area. It also allows visualization of hyaluronic acid (HA) gel within the soft tissue.

OBJECTIVES

The authors investigate the difference in the distribution pattern between 2 HA fillers in the periocular tissue using HRUS.

METHODS

The charts of 10 patients who underwent periocular injection using HA gel filler and were subsequently examined with HRUS were reviewed. Half of the patients (n = 5) were treated with Restylane-L (Medicis Aesthetics, Inc, Scottsdale, Arizona) and the remaining 5 with Belotero Balance (Merz Aesthetics, Inc, San Mateo, California). Ultrasonographic evaluation (Logiq p6; GE Healthcare, Waukesha, Washington) was performed before and immediately after HA filler injection.

RESULTS

The HA appears as a hypoechoic image within the soft tissue plane on HRUS. Restylane-L filler formed a localized hypoechoic image within the tissue, with some spread into bubbles or pearl-like configuration. Belotero Balance spread more widely into the tissue plane and diffused into an elongated or spindle-shaped hypoechoic image.

CONCLUSIONS

Our preliminary data suggest that HA gel fillers with differing production technologies show distinct spread and distribution patterns in the periocular tissues on HRUS examination.

Orofacial dermal fillers: foreign body reactions, histopathologic features, and spectrometric studies

OBJECTIVE

The aim of this study is to assess the different histopathologic presentations of dermal filler materials-induced foreign body reactions by spectrometric analyses.

STUDY DESIGN

Sixteen cases of dermal filler foreign body reactions in the orofacial region were retrieved from the 2006-2013 period. The histologic features were evaluated and categorized into 5 groups (I to V). Unstained deparaffinized sections of representative tissue from one case in each of groups I to IV were sent for spectrometric analysis, along with samples of 2 popular dermal fillers (Juvéderm and Radiesse).

RESULTS

With the help of spectrometric analysis, we were able to correlate the histopathologic presentations with the specific type of dermal filler used.

Dynamic high-resolution ultrasound in vivo imaging of hyaluronic acid filler injection

BACKGROUND

High-resolution ultrasound (HRU) imaging is a useful tool to study hyaluronic acid (HA) filler injected in the face.

OBJECTIVE

To observe real-time injection of HA using HRU and describe behavior of the gel injection in various anatomic layers and the effect of massage.

METHODS

Deep (preperiosteal), intermediate (subdermal), and superficial (dermal) injections of HA were performed in the supraclavicular area under ultrasonography visualization on a healthy volunteer. Videos were obtained during injection and static images at several time points, including during injection, immediately after injection, 5 minutes after massage of the treated area, and at 2 weeks after injection.

RESULTS

During injection, dermally injected HA stayed within the dermis, increasing its echogenicity; subdermally injected HA formed multiple anechoic pearls; and preperiosteal HA produced a single anechoic bubble with diffuse margins. No vertical transection of the planes was observed during injection or after massage. Two-week postinjection imaging showed persistence of the varying HA morphology in each plane.

CONCLUSIONS

High-resolution ultrasound allows in vivo study of HA injection behavior. HA adopts different morphology within the tissue depending on the density and compliance of the tissues in the plane of injection.

Hyaluronic acid filler injections for tear-trough deformity: injection technique and high-frequency ultrasound follow-up evaluation

This study aimed to describe the technique used by the authors in treating tear-trough deformity and to illustrate the effectiveness of high-frequency diagnostic ultrasound in the assessment of dermal filler longevity. In this consecutive interventional nonrandomized case series, 22 patients (18 women and 4 men) were evaluated. They ranged in age from 29 to 65 years (mean, 46.59 years ± 10.0 years). The patients were given multiple hyaluronic acid injections in the tear-trough area between 2009 and 2011. The injected areas then were evaluated with sonographic scans during the follow-up period. All the patients were examined preoperatively, 7 days after injection, then after 1, 6, and 12 months, and finally once a year. Pre- and postoperative photographs using standard positioning and lighting were taken as well as high-frequency ultrasound scans using a 15-MHz scanner with an axial resolution of 15 mm. The injection technique consisted of three to five injections perpendicular to the skin. These were administered just under the orbital rim, creating three column-shaped hyaluronic acid deposits deep in the orbicularis oculi muscle, from 0.2 mm to 0.5 mm below the orbital rim. Approximately 0.1 ml-0.3 ml was injected at a time. This technique creates a deep scaffolding that can fill the orbital hollow. The amount of filler used in each area ranged from 0.1 ml to 0.3 ml (mean, 0.267 ml ± 0.128 ml), whereas the mean filler quantity in each eyelid was 0.45 ml ± 0.14 ml. During the follow-up visit 1 week after the treatment, 21 patients (90 %) required a second series of injections either in the exact same areas or right next to the injected area to obtain a smoother appearance of the skin surface. During the sonographer examination, it was always possible to identify and measure the filler at the site of the injection.

LEVEL OF EVIDENCE IV

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Dermal filler complications from unknown biomaterials: identification by attenuated total reflectance spectroscopy

BACKGROUND

In the last decade, an increase in complications related to dermal filler injections has been reported, especially in patients who underwent multiple treatments with different products. Imaging or histological examinations may suggest what kind of substance was used, but none can precisely identify the biomaterial. The aim of this study was to evaluate the use of Fourier transform infrared spectroscopy, using an attenuated total reflectance cell, in the identification of unknown dermal fillers.

METHODS

In the preclinical study, samples from different manufacturers were analyzed according to attenuated total reflectance spectroscopy using the Nicolet 8700 FT-IR spectrophotometer (resolution, 0.125 cm; Thermo Fisher Scientific, Inc., Madison, Wis.). Spectra of each biomaterial were collected and included in a reference database. In the clinical study, seven patients affected by severe complications due to multiple injections with unknown fillers provided a sample of the pathological tissue for the analysis.

RESULTS

Two granulomas, two infiltrated tissues, and three abscesses were studied. Attenuated total reflectance/Fourier transform infrared analysis of pathological tissues revealed the presence of absorption bands absent in the healthy tissue. Comparison of these bands to the filler database made it possible to identify the dermal fillers injected.

CONCLUSIONS

This pilot study has demonstrated the absolute validity of the application of infrared spectroscopy in attenuated total reflectance for the determination of infiltrated biomaterial. The knowledge of the previously injected fillers may be crucial to selecting the appropriate medical or surgical treatment as well as to solving medical-legal issues.

Non-invasive assessment of negative pressure wound therapy using high frequency diagnostic ultrasound: oedema reduction and new tissue accumulation

Tissue oedema plays an important role in the pathology of chronic and traumatic wounds. Negative pressure wound therapy (NPWT) is thought to contribute to active oedema reduction, yet few studies have showed this effect. In this study, high frequency diagnostic ultrasound at 20 MHz with an axial resolution of 60 µm was used to assess the effect of NPWT at - 80 mmHg on pressure ulcers and the surrounding tissue. Wounds were monitored in four patients over a 3-month period during which changes in oedema and wound bed thickness (granulation tissue) were measured non-invasively. The results showed a rapid reduction of periwound tissue oedema in all patients with levels falling by a mean of 43% after 4 days of therapy. A 20% increase in the thickness of the wound bed was observed after 7 days due to new granulation tissue formation. Ultrasound scans through the in situ gauze NPWT filler also revealed the existence of macrodeformation in the tissue produced by the negative pressure. These preliminary studies suggest that non-invasive assessment using high frequency diagnostic ultrasound could be a valuable tool in clinical studies of NPWT.

The utility of high-frequency ultrasound in dermal filler evaluation

Aim of this study is to describe the use of high-frequency ultrasound to ascertain the site, quantity, and type of filler injected in the soft tissue of the face, with respect to reliability of the procedure and the analysis costs. Between December 2006 and August 2010, 80 subjects aged 25 to 65 years, who underwent facial filler augmentation, were submitted to high-frequency sonography. Of total, 42 patients (22 after temporary filler and 20 after permanent filler) were healthy and satisfied of the treatment, and 38 patients sought consultation for filler-related problems. The nature of the injected filler was known in 86.25% of the patients, whereas it was unknown in 13.75% of the patients. Besides 4 patients, previously treated with temporary products, in which no foreign material was detected, high-frequency sonography was able to identify and quantify the presence of filler in the soft tissue of 97% of patients. Moreover, it was possible to detect inflammatory reaction (that were often silent), granulomas, and recognize the presence of diverse fillers in the same area. Ultrasonography has proved to be a useful, inexpensive, noninvasive tool for the identification of the site, quantity, and often even nature of the filler injected.

Common applications of dermatologic sonography

In recent years, there has been growing use of sonography in the dermatologic field. Thus, this review analyzes the most common dermatologic applications of sonography with some technical considerations for performing this type of examination. Moreover, the sonographic findings in common benign and malignant skin tumors, inflammatory dermatologic diseases, and ungual and cosmetic conditions, among others, are considered. Thus, this noninvasive technique may be a potent adjunctive tool in the diagnosis and management of dermatologic conditions in daily practice, delivering critical information otherwise unavailable to the clinical naked eye.

High-frequency sonography of temporary and permanent dermal fillers

BACKGROUND

Dermal fillers are used widely; some have a permanent effect, whereas others are temporary. The aim of this study is to describe the ultrasonographic features of permanent and temporary fillers injected into patients for cosmetic purposes.

MATERIALS AND METHODS

Between December 2006 and April 2009, 36 subjects, aged 25-45, who had received lips or nasolabial fold filler augmentation, were enrolled for a high-frequency sonographic examination by a blinded investigator. The criteria for exclusion were a history of autoimmunity, infection, neoplastic diseases or episodes of local reactions to the injected filler. Twenty patients underwent a sonographic exam after the injection of a temporary filler (collagen or hyaluronic acid) by FRG; the rest were enrolled among patients seeking a consultation for further cosmetic reasons, but had been treated with an identifiable filler before.

RESULTS

It was always possible to identify the filler at the site of injection. Seldom was it possible to discover a silent inflammatory reaction, otherwise unsuspected. The sonographic images differed according to the temporary or the permanent nature of the filler.

CONCLUSION

Ultrasonography has proved to be a useful, non-invasive tool for the identification of the presence and type of the filler injected.