The Rise of Complications

Every day the use of exogenous material within aesthtic treatment, specifically within filler treatment procederes, are becoming more and more common. Recent data from the American Society of Plastic Surgery (ASPS) confirms that in fact fillers are the second most common non-invasive 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 immunological reactions, not carcinogenic, not teratogenic, not migrating, biocompatible, and biodegradable. But above all, it must be injectable, and when used routinely the technique and the results should be reproducible. In addition to its many necessary qualities, it must also be cost effective to maintain industry value and remain accessible to patients.

Unfortunately, however, a substance that meets all these characteristics does not yet exist. Therefore, it is possible that when injecting fillers multiple complications may appear, including simple to severe disfigurement, irreversible sequelae, and even blindness or hemiparesis. To make the scenario even more difficult, complications can occur with both medically approved substances (such as hyaluronic acid) and non-medically approved products (such as silicone in oil.) Fillers can be injected by qualified physicians or non physicians and can even constitute a question of malpractice. This has become such a complex scenario, the complications derived from all filler products and procedures have been considered problematic in the practice of modern, safe medical aesthetic treatment.

The Need for New Tech

In many cases, complications can appear early or delayed, sometimes many years after the filler procedure, and patients may deny or even forget the use of them. Their clinical implementation is diverse and often imprecise, and can simulate multiple dermatological pathologies.

Practically, the difficulty in determining the precise diagnosis of these complications is often due to a clinical imaging challenge. Some diagnostic modalities such as Magnetic Resonance have been used for the characterization of exogenous materials, mainly due to their excellent spatial and anatomical resolution, but it is unable to establish precisely the type of substance injected. Although there are silicone suppression sequences (which in theory would allow one to differentiate the substance from other types of fillers) the other types of filler can have an appearance similar to silicone in MRI, making them practically indistinguishable from each other. Computerized axial tomography does not have any indication in the identification of this type 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 a reliable determinant, given that metabolic increase can be seen in patients with or without filler injection complications.

High Resolution Ultrasound: The Future of Complication Treatment

High-resolution dermatological ultrasound with linear transducers from 14 to 24 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 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, as well as inflammatory and non-inflammatory nodules) can also be characterized with dermatological ultrasound, and the differentiation of these complications with diseases that may have an identical clinical presentation (ie. morphea, sarcoidosis or cutaneous lymphoma) can be adequately determined. Ultrasound procedure must be carried out by personnel with specific training and follow the suggested guidelines for dermatological use.

Over the course of almost 12 years dedicated exclusively to dermatological ultrasound, there have been many cases where I, personally, have diagnosed a variety of complications related to the use of filler material, ranging from mild complications to devastating sequelae reactions that will mark the lives of patients forever. In all of my experiences, ultrasound has provided valuable information for myself, my clinical colleagues, fellow dermatologists, and plastic surgeons to assertively manage and treat patients.

Bibliography

• Worstman X. Identification and Complications of Cosmetic Filler:Sonography First.J Ultrasound Med. 2015 Jul; 34(7):1163-72. 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): 5064-8.
• 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: e111-4.
• Gonzalez C, Gonzalez C,Barbosa E et all. High Resolution Ultrasound of Fillers and their implications in Aesthetic Medicine:A study in Human Cadavers .Int J Clin Expo Dermatol, 2021.