Amid a rise in the use of cosmetic fillers -- commonly injected in the face for anti-aging effects -- Doppler high-frequency ultrasound (HFUS) picked up "highly variable" findings in filler-related vascular adverse events (VAEs), researchers reported.
Among 100 participants in an international retrospective cross-sectional study, the most common VAEs were absent flow in perforator vessels (42%) and absent flow in major vessels (35%), reported Rosa Maria Silveira Sigrist, MD, of the University of São Paulo Department of Radiology in Brazil, at the Radiological Society of North America (RSNA) annual meeting in Chicago.
Beyond these, though, "the findings are highly variable," which, she said, "highlights the need to recognize all possible Doppler patterns to support diagnosis and guide management."
The next most common VAEs identified were compensatory flow in adjacent or branching vessels (26%), string sign (18%), and increased peak systolic velocity (16%). Doppler abnormalities moderately correlated with absent flow in the lateral nasal artery (Φ=0.37, P=0.00042) and columellar artery (Φ=0.34, P=0.00136) -- both high-risk arteries for necrosis and visual complications, Sigrist added.
"We know that the use of cosmetic fillers has been growing a lot, and so [have] the vascular complications, including necrosis, blindness, and even stroke," Sigrist said during the presentation. "And unlike other systems, like the carotid or peripheral vessels, where Doppler criteria for stenosis and occlusions are very well established, for the face things are different. The facial vasculature is highly complex and extremely anastomosed, and we lack standardized Doppler criteria for these complications."
"Our main objectives were to identify the most frequent findings related to vascular complications to support diagnosis and management, and also to evaluate whether these findings are associated with the use of hyaluronidase, which is the enzyme that breaks down hyaluronic acid [a common filler material]," she said.
Most study participants had been injected with hyaluronic acid. But, there were no differences in Doppler findings between the 79% of participants who received hyaluronidase before ultrasound imaging and the 21% who did not get these injections to treat filler-related complications. Nor did hyaluronidase prior to ultrasound imaging significantly correlate with any specific Doppler findings, Sigrist reported.
The study involved patients seen for VAEs from May 2022 through April 2025 by four radiologists in Brazil, Chile, and Colombia, one aesthetic medical doctor in the Netherlands, and one plastic surgeon in the U.S. Participants in the study had an average age of 38 and 88% were female. These medical professionals completed a structured questionnaire on their Doppler use.
There was heterogeneity in terms of how Doppler HFUS was used by examiners, indicating a need for standardized facial Doppler protocols for reproducibility and optimal outcomes, Sigrist noted.
Only half of examiners used microvascular Doppler technologies, Sigrist highlighted. "What was really a surprise to me," she said, "is that the criteria for peak systolic velocity in facial vascular occlusions ... we did not have a consensus on that." Related findings included that "half of the examiners did not know which reference value to use for these complications," she noted.
One question from the audience pertained to why Doppler HFUS might be better than MRI or CT imaging when it comes to filler-related VAEs. Sigrist pointed to a number of potential factors, including that Doppler HFUS doesn't require contrast, that ultrasound imaging is more readily available than the other imaging modalities, and that the availability of microvascular technologies is important, as is having real-time examination in patients.
Disclosures
Sigrist reported consultant fees from GE Healthcare. Co-authors also reported consultant and speaker fees as well as other relationships with industry.
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