Dermatologic Ultrasound—The first modality of choice in the diagnosis and management of complications due to the use of cosmetic fillers
Each day, the use of exogenous materials for aesthetic purposes (known as fillers) is more common. Recent data from the American Society of Plastic Surgery (ASPS) confirmed that it is the second most common noninvasive medical procedure, followed by the use of botulinum toxin.
It has been described that the ideal filler material must meet certain characteristics: be cosmetically effective, not allergenic or induce immunologic reactions, not carcinogenic, not teratogenic, not migrating, biocompatible, biodegradable, and injectable. When used routinely, the technique and the results should be reproducible. Finally, in addition to what is described, it must be cost effective.
Unfortunately, a substance that meets all of these characteristics does not yet exist and, therefore, it is possible that with the use of cosmetic fillers, multiple complications may appear, from very simple to severe disfigurement, irreversible sequelae, and even blindness or hemiparesis. To make the scenario even more difficult, complications can occur with medically approved substances such as hyaluronic acid or with substances not medically approved for cosmetic use such as silicone in oil.
Fillers can be injected by qualified physicians or nonphysicians and constitute a problem of malpractice. In my country, Colombia, this has become such a complex scenario, the complications derived from all these types of products and procedures have been considered a public health problem, and the situation may not be different in other countries of the world.
In many cases, complications can appear early or late, even many years after the filler application, and patients may not remember or even deny the use of them. Their clinical presentation is diverse and imprecise and can simulate multiple dermatologic pathologies. In this complex scenario, the precise diagnosis of these complications represents a clinical and imaging challenge.
Some diagnostic modalities, such as magnetic resonance imaging (MRI), have been used for the characterization of exogenous materials, mainly due to their excellent spatial anatomic resolution but, it is unable to establish precisely the type of substance injected. Although there are silicone suppression sequences, which in theory would allow differentiation of this substance from other types of fillers, the truth is that other types of fillers can have an appearance similar to silicone in MRI, which manifests as “silicone like”, being indistinguishable from each other or with multiple inflammatory skin conditions.
Computerized axial tomography does not have any indication in the identification of these types of substances and positron emission tomography (PET)-CT is not recommended for the evaluation of injectable material because the increase in metabolic activity is not specific and can be seen in patients with or without complications caused by the injection of the fillers.
High-resolution dermatologic ultrasound with linear transducers from 14- to 22-MHz has proven to be a very precise diagnostic tool to differentiate the type of filler injected and the complications derived from them, avoiding misdiagnosis and the use of unnecessary biopsies. Substances such as hyaluronic acid, calcium hydroxyapatite, silicone, polymethylmethacrylate, and polycaprolactone, among others, have a unique and characteristic ultrasound appearance that allows them to be easily differentiated from the others.
Late or early complications such as the development of dermatopathies, hypersensitivity reactions, migration of the filler material, inflammatory and noninflammatory nodules, can also be characterized with dermatologic ultrasound and the differentiation of these complications from diseases such as morphea, sarcoidosis, or cutaneous lymphoma that they may have an identical clinical presentation can be adequately performed by ultrasound. The study must be carried out by personnel with specific training and follow the suggested guidelines for the use of dermatologic ultrasound.
During my almost 10 years dedicated exclusively to dermatologic ultrasound, I have diagnosed many cases with all these types of complications related to the use of filler material, cases with mild complications or devastating stories of patients with sequelae that will mark your life forever. In all of them, ultrasound has provided valuable information with which my clinical colleagues, Dermatologists and Plastic Surgeons, have assertively managed their patients.
Bibliography
- Worstman X. Identification and complications of cosmetic filler: sonography first. J Ultrasound Med 2015 Jul; 34(7):1163–1172. DOI: 10.7863/ultra.34.7.1163.
- .Cavallieri F. Adventages of sonography in fillers and complications. In Image Guided Dermatologic Treatments. Switzerland. Springer 2020. pp93–102.
- González C. High resolution ultrasound of soft tissues for characterization of fillers and its complications. Rev Colomb Radiol 2019; 30(1): 5064–5068
- Worstman X, Alfagame F, Roustan G, Arias-Santiago S, Martorell A, Catalano O, Scotto M, Zarchi K, Bouer M, González C, Bard R, Mandava A, Gattini D. Guidelines for performing dermatologic ultrasound examinations by the DERMUS group. J Ultrasound Med 2016; 35: e111–e114.
Claudia Gonzalez, MD, is a radiologist at IDIME in Bogotá, Colombia, and is Secretary of the Dermatologic Ultrasound AIUM Interest Group, High Resolution Dermatological and MSK Ultrasound.
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