SONOGRAPHIC PATTERNS OF COSMETIC FILLERS
CF generate different patterns and artifacts in US,
and those depend on the agent.
The most common ones are:
- Snowstorm,
- Cottony,
- Vacuolar,
and
- Posterior acoustic shadowing.
Fig. 13: Sonographic patterns of dermal/hypodermal cosmetic fillers
Vacuolar Pattern:
- Well defined anechoic pseudocyst appearance.
- Posterior acoustic enhancement with side acoustic shadowing.
- No internal vascularity on color Doppler.
- Deposits decrease in time or desappear over time.
- Hyaluronic Acid and Polyacrylamide
Fig. 14: Vacuolar Pattern
(A). HRUS of the face showing oval shaped anechoic pseudocyst in the subcutaneous tissue in a patient with a known prior history of dermal injections of hyaluronic acid in the nasolabial folds.
(B). Scheme of the vacuolar pattern.
Snow Storm Pattern:
- Hyperechoic deposits with posterior reverberation artifact.
- Do not modify their size or characteristics overtime.
- Silicone and methyl methacrylate.
Fig. 15: Snow Storm Pattern.
(A). HRUS of the face showing hyperechoic deposits with posterior reinforcement or reverberation artifact, better known as snow storm pattern, inside some lymph nodes of the right jugular chain, corresponding to migration of silicone and biopolymers in a patient with prior history of CF injections.
(B). Scheme of the snow storm pattern.
Cottony Pattern:
- Heterogenous echogenicity with a cottony appearance.
- Predominantly due to changes inherent in resorbable fillers
- Degradation of hyaluronic acid
Fig. 16: Cottony Pattern.
(A). US of the face in a patient with prior history of Hyaluronic acid injections, at the beginning with vacuolar pattern, and now with a cottony pattern as a sequel of those prior HA injections.
(B). Scheme of the cottony pattern.
References: Actas Dermosifiliogr. 2015; 106 (Supl 1): 87-95
Acoustic Shadowing Pattern:
- Hyperechogenic deposits with posterior acoustic shadowing artifact.
- Do not modify size or characteristics over time.
- Calcium hydroxyapatite
Fig. 17: Acoustic Shadowing Pattern.
(A). HRUS of the face showing hyperechoic deposits with posterior acoustic shadowing, corresponding to a filling agent in a patient with prior history of calcium hydroxyapatite injections.
(B). Scheme of the acoustic shadowing pattern.
DERIVED COMPLICATIONS
HRUS is an effective tool either for diagnosis of filling agents,
as well as for management and detection of complications and adverse reactions.
The complications derived from its use and adverse reactions range from just mild edema to skin necrosis,
being the most common: palpable nodularities,
migration and inflammatory reactions.
Some of the complications described are listed below:
- Persistent nodularities or palpable cords
- edema and erythema - Inflammatory dermopathy
- Fistulizations
- Abscesses and infections
- Necrosis of the skin
- Morphea-like reaction
- Migration.
Nodules:
- Usually as a palpable nodule on clinical examination (Fig. 19).
- it may be evident without palpation.
Fig. 19: (A). Clinical picture of the patient (permission given).
(B) And (C). HRUS. Round shaped anechoic pseudocyst localized on both jawlines corresponding to hyaluronic acid injections.
(D) And (E). HRUS. Right nasolabial fold, corresponding to the site of patient’s complaint, showing an hyperechoic oval shaped “lesion” with some areas of posterior reverberation artifact (snow storm) and other areas os posterior acoustic shadowing (mixed pattern) corresponding to non-absorbable filling agent.
Fig. 20: (A). HRUS. Left nasolabial fold, corresponding to site of palpable nodule, shows a small anechoic pseudocyst (1,6 mm) demonstrating posterior reinforcement for resorbable filling agent.
(B) And (C) HRUS, both cheeks, longitudinal view, with diffuse snow storm pattern appeareance caused by a permanent – non-resorbable filling agent.
Edema and erythema:
- Dermal inflammatory reaction (Fig. 21).
- It may be recurrent and severe (Fig. 22).
Fig. 21: (A). Clinical picture of the patient (permission given).
(B). Power Doppler ultrasound showing increased blood flow surrounding the lesion due to inflammatory changes.
(C) and (D) longitudinal view HRUS. Comparison of normal and abnormal dermal tissue in a patient with recent history of hyaluronic acid + vitamins dermal injections on both cheeks. Some hypoechoic pseudocysts with inner echoes due to debris associated to increased in echogenicity of surrounding tissue.
Fig. 22: Recurrent Severe Inflammatory Reaction
(A). Clinical picture of the patient (permission given). Photos of the patient in three different episodes of the disease. The US was performed at the time of the first photo from left to right.
(B). Right nasolabial fold. Cottony pattern as as sequel of hyaluronic acid injections.
(C). Right cheek. Diffuse alteration of soft tissues on right cheek and nasolabial fold visualizing some milimetric pseudocyst corresponding to resorbable filling agent, and some areas of snow storm artifact indicative of non-resorbable agent.
(D) Comparison between both nasolabial folds and marionette lines, showing diffuse snow storm pattern, with a small pseudocyst on the left side.
Migration:
- Migration of the filling agent to a different site from that of primary implantation (Fig. 23,
Fig. 24).
Fig. 23: (A). Clinical picture of the patient (permission given).
(B), (C) and (D). HRUS. Mid-Forehead, corresponding to the site of patient’s complaint showing some small nodules (arrows) indicative of hyperechoic deposits of a filling agent with snow storm pattern.
Fig. 24: (A). HRUS at the level of the jawline and submandibular area, showing a small anecoich pseudocyst (blue arrow), corrresponding to a resorbable CF. It is also visualized hyperechoic deposits with posterior reverberation artifact on a lymph node (yellow arrow), corresponding to migration of silicone and biopolymers in a patient with prior history of CF injections.
(B). Hyperechoic deposits with posterior reinforcement or reverberation artifact, better known as snow storm pattern, inside some lymph nodes of the right jugular chain (yellor arrow), corresponding to migration of CF.