Description of a safe doppler ultrasound‐guided technique for hyaluronic acid filler in the face—A method to avoid adverse vascular events

Abstract

Background: Knowledge of facial anatomy is essential for professionals intending to inject hyaluronic acid (HA) into that region, but due to the considerable anatomical variations in region, it does not guarantee the complete safety of the procedure.Similarly, procedures widely disseminated among professionals, such as aspiration and the use of cannulas, do not ensure total safety against vascular occlusion events caused by the filler.Objectives: This article describes a technique for injecting hyaluronic acid into the face guided by Doppler ultrasonography (DUS) in order to ensure greater safety against vascular occlusion events secondary to the procedure. Methods:We describe a Doppler ultrasound-guided filling technique, with an 18 MHZ transducer, consisting of three steps: arterial mapping, real-time ultrasound-guided filling, and assessing the perfusion. Results:The described technique was performed in 480 patients and can be adopted in the routine of professionals who inject hyaluronic acid, especially in areas at high risk for vascular events. Its use results in greater safety against vascular occlusion events secondary to the procedure, without the need for prior aspiration. We conclude that there is a local vasodilation right after the filling that makes it difficult the possibility of extrinsic compression exerted by the filler on the vessel. Furthermore, the product moves to deep planes even with the bevel facing up (toward the epidermis). Conclusions:We believe that in the future the use of Doppler ultrasound-guided filling technique will be mandatory for professionals who intend to perform HA injection, to both ensure patient safety and provide legal protection for the professional.

Ischemic complications of dermal fillers

“…Doppler ultrasound has been seen to detect anatomy, such as the facial artery lateral to the nasolabial fold, along with its different anatomical variations [109] . One other study commented that although ultrasound may be difficult to manage in conjunction with injection, a new technique combining 3D time of flight magnetic resonance angiography (3D-TOF MOTSA MRA) and infrared (IR) facial heating could visualize the following arteries: facial, angular, superior labial, inferior labial, lateral nasal, dorsal nasal, supratrochlear, supraorbital, and superficial temporal [110] . These images could be acquired on a 1.5 or 3 Tesla (T) system with a head coil, with an additional surface coil on top, to improve signal reception [110] .…”

“…One other study commented that although ultrasound may be difficult to manage in conjunction with injection, a new technique combining 3D time of flight magnetic resonance angiography (3D-TOF MOTSA MRA) and infrared (IR) facial heating could visualize the following arteries: facial, angular, superior labial, inferior labial, lateral nasal, dorsal nasal, supratrochlear, supraorbital, and superficial temporal [110] . These images could be acquired on a 1.5 or 3 Tesla (T) system with a head coil, with an additional surface coil on top, to improve signal reception [110] . The authors showed that these MRA images could be projected on the patient's face before injection, albeit without the same 3D depth aspect [110] .…”

“…These images could be acquired on a 1.5 or 3 Tesla (T) system with a head coil, with an additional surface coil on top, to improve signal reception [110] . The authors showed that these MRA images could be projected on the patient's face before injection, albeit without the same 3D depth aspect [110] .…”

“…The main benefit of this method was visualization of the facial arteries in a non-invasive and contrast-free manner [110] . However, the cost of MRI in these individual countries may need to be considered before the widespread adoption of this technology.…”

Bridging a Century-Old Problem: The Pathophysiology and Molecular Mechanisms of HA Filler-Induced Vascular Occlusion (FIVO)—Implications for Therapeutic Interventions

“…In mouse and rabbit FIVO models, arterial compression by filler could not be induced and did not result in any prolonged period of significant underperfusion or ischemia [ 110 , 111 ]. In humans, single-point obstructions of facial vessels are easily overcome by a vastly redundant blood supply from adjacent angiosomes, via true anastomoses, which dilate post filler-placement [ 112 ]. Even in instances of bilateral external carotid artery (ECA) ligation, historically performed for intractable epistaxis, compensatory flow from the internal carotid artery (ICA) system has been sufficient to avoid tissue necrosis [ 113 , 114 , 115 ].…”