Ultrasound Shows Promise in Managing Filler Complications, RSNA Study Finds

Ultrasound imaging could play a key role in improving both the safety and treatment of cosmetic filler injections, according to new research presented at the 2025 Radiological Society of North America (RSNA) annual meeting.

With more than 5.3 million hyaluronic acid filler procedures performed in the U.S. in 2024 alone, the popularity of minimally invasive cosmetic enhancements continues to surge. But as demand grows, so does concern over complications—particularly vascular occlusion, a serious event where filler material blocks blood flow in facial arteries. If left untreated, such blockages can lead to tissue necrosis, permanent facial damage, or in rare cases, even blindness or stroke.

"Vascular occlusion events in the face can be devastating, because, if they’re not properly treated, they can cause necrosis and even facial deformation," said Rosa Maria Silveira Sigrist, M.D., an attending radiologist and Ph.D. candidate at the University of São Paulo.

To explore how imaging could improve outcomes, Dr. Sigrist and her colleagues analyzed ultrasound findings in 100 patients with suspected filler-related complications. The study spanned six centers across Brazil, including radiology, dermatology, and plastic surgery clinics, between May 2022 and April 2025.

The most common ultrasound observation was an absence of flow in perforator vessels, found in 42% of patients. In 35% of cases, researchers identified absent blood flow in major vessels—especially involving the lateral nasal artery, a region known for its complex vascular connections.

"Nasal vessels communicate with the external carotid system via the facial arteries and with the internal carotid system through the retina," Dr. Sigrist noted. "This makes the nose a high-risk injection area, where misplacement of filler can result in very severe consequences."

Current treatment protocols for vascular occlusion typically rely on injecting hyaluronidase, an enzyme that dissolves hyaluronic acid. However, without imaging, these injections are often administered blindly based on visible symptoms. According to Dr. Sigrist, ultrasound allows for a more targeted approach.

"If injectors are not guided by ultrasound, they treat based on where the clinical findings are and inject blindly," she said. "But if we can see the ultrasound finding, we can target the exact place where the occlusion occurs. Rather than flooding the area with hyaluronidase, we can do guided injections that use less hyaluronidase and provide better treatment results."

In addition to treating complications, the study suggests ultrasound can be an effective preventative tool. By guiding initial filler placement, ultrasound may reduce the risk of vascular injury while optimizing filler use and injection precision.

Although ultrasound criteria for vascular imaging are well established in other parts of the body, such as the carotid arteries and limbs, the facial vasculature remains uniquely complex and variable. Dr. Sigrist’s team aims to fill that gap by outlining a standardized reference for recognizing and managing filler-related vascular events.

This evolving role of ultrasound in aesthetic medicine could help providers detect, prevent, and treat complications more effectively—potentially reshaping protocols for both cosmetic procedures and their emergency interventions.

Study co-authors include Maria Cristina Chammas, M.D., Ph.D., Ximena Wortsman, M.D., Claudia Gonzalez, M.D., Fernanda A. Cavallieri, M.D., Stella Desyatnikova, M.D., and Leonie Schelke, M.D.