Ultrasound: Treating Vascular Adverse Events Caused by Hyaluronic Acid Fillers

Hyaluronic acid (HA) fillers, celebrated for their safety profile, occasionally pose risks of severe vascular adverse events. To enhance treatment outcomes, a recent study, published in the Journal of the American Academy of Dermatology, unveiled the use of duplex ultrasonography (DUS) in identifying the HA filler responsible for intra-arterial obstructions, reducing the risk of skin necrosis.

The study examined the use of DUS in detecting and targeting HA fillers causing vascular occlusions. This technique has shown promising results in guiding the administration of hyaluronidase—a key enzyme used to dissolve HA fillers in the event of postinjection complications.

Twenty-one patients referred for vascular occlusions due to HA injections in facial areas such as the lips, nose, forehead, chin, and cheeks were enrolled in the study. Ultrasonographically-guided injections of 35 to 50 units of hyaluronidase were administered into obstructing intravascular filler deposits. The treatment resulted in an immediate restoration of blood flow, significantly improving the livedo reticularis aspect of the skin.

The use of DUS provided critical insights into the depth, location, and size of soft tissue fillers, enabling the identification of HA deposits responsible for intravascular blockages. This real-time guidance not only dissolved the obstructive filler but also led to rapid improvements in blood flow and, subsequently, clinical outcomes.

The findings suggest that the deposition of HA fillers in an artery could trigger an arterial spasm, leading to ischemic events. DUS examination revealed marked vascular changes before and after ultrasonographically-guided hyaluronidase injection, supporting the hypothesis that obstructive filler deposits in arterial regions are dissolved by the hyaluronidase, immediately restoring blood flow and alleviating the ischemic symptoms.

The study emphasized that ultrasonography, due to its ability to visualize and differentiate filler types, offers crucial guidance for precise and low-dose hyaluronidase injections, regardless of the HA filler type used. This method significantly reduced the need for high-dose hyaluronidase applications, minimizing the risk of potential negative side effects and retinal toxicity.

“Because the use of duplex ultrasonography adds extra essential information, its use may become an integral part of the prevention and treatment of injection adverse events,” concluded the study authors.

Reference

Schelke LW, Velthuis P, Kadouch J, Swift A. Early ultrasound for diagnosis and treatment of vascular adverse events with hyaluronic acid fillers. J Am Acad Dermatol. 2023;88(1):79-85. doi:10.1016/j.jaad.2019.07.032