Clinical value of high-resolution (5–17 MHz) echo-color Doppler (ECD) for identifying filling materials and assessment of damage or complications in aesthetic medicine/surgery

  • Maria Scotto di Santolo
  • Candida Massimo
  • Giovanni Tortora
  • Valeria Romeo
  • Michele Amitrano
  • Arturo Brunetti
  • Massimo Imbriaco



The purpose of this retrospective study is to evaluate the role of echo-color-Doppler (ECD) imaging in identifying a series of characteristics pursuant to aesthetic filling material such as their degree of absorbability and their potential complications which include their propensity to stimulate the formation of encapsulated foreign-body granulomas. In the latter case, ECD can be of aid by giving indication for surgical therapy.

Materials and Methods

Over a 4-year period, we studied 180 patients (60 ♂) who underwent an aesthetic medical/surgical treatment. We used ECD to evaluate the implant material, its thickness, the injection site, the integrity of dermal layers and the presence of any associated complications.


In 97% (174/180) of our patients, we were able to identify the type of material used; furthermore, 57% of patients had a hyaluronic acid implant, 14% a lipofilling and 29% a non-absorbable filler (with 10% of silicone). In 6/180 (3%), we could not recognize the material used; 89% (161/180) of our patients presented post-injection complications; moreover, 67% showed peri-implant dermal–hypodermal thickening areas with adjacent lymphostasis, 6% displayed an abnormal implant site, and 17% showed inflammation with encapsulated foreign-body granulomas that required subsequent surgical excision. Biopsy samples were obtained from 37/180 patients (21%); among these, 31 patients had an ECD evidence of granuloma and on 6 patients we were not able to define the injected material. Histopathological examination identified 29 granulomas, 5 sterile abscesses and 3 chronic inflammations in the absence of granuloma. ECD showed an overall 78% diagnostic accuracy, with 90% sensitivity and 37% specificity in detecting filler granulomas.


ECD is a low-cost technique that allows to identify filling materials and to assess the complications of an esthetic medical/surgical treatment.


Skin ultrasound Color-Doppler high-resolution ultrasound Skin lesion Filler Granuloma 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest related to the publication of this article.

Ethical approval

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Scotto di Santolo M, Sagnelli M, Mancini M et al (2015) High-resolution color-Doppler ultrasound for the study of skin growths. Arch Dermatol Res 307(7):559–567. CrossRefPubMedGoogle Scholar
  2. 2.
    Scotto di Santolo M, Sagnelli M, Tortora G et al (2016) The utility of the high-resolution ultrasound technique in the evaluation of autologous adipose tissue lipofilling, used for the correction of post-surgical, post-traumatic and post-burn scars. Radiol Med 121(6):521–527. CrossRefPubMedGoogle Scholar
  3. 3.
    Alexander H, Miller DL (1979) Determining skin thickness with pulsed ultrasound. J Invest Dermatol 72(1):17–19CrossRefGoogle Scholar
  4. 4.
    Wortsman X, Alfageme F, Roustan G, Arias Santiago S, Martorell A, Catalano O, Scotto di Santolo M, Zarchi K, Bouer M, Gonzalez C, Bard R, Mandava A, Gaitini D (2016) Guidelines for performing dermatologic ultrasound examinations by the DERMUS group. J Ultrasound Med 35:111–114CrossRefGoogle Scholar
  5. 5.
    Wortsman X, Alfageme F, Roustan G, Arias Santiago S, Martorell A, Catalano O, Scotto di Santolo M, Zarchi K, Bouer M, Gonzalez C, Bard R, Mandava A, Gaitini D (2016) Proposal for an Assessment Training Program in Dermatologic Ultrasound by the DERMUS Group. J Ultrasound Med 35:e5–e9.|
  6. 6.
    Srivastava A, Woodcock JP, Mansel RE et al (2012) Doppler ultrasound flowmetry predicts 15 year outcome in patients with skin melanoma. Indian J Surg 74(4):278–283. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Daines SM, Williams EF. Complications associated with injectable soft tissue fillers: a 5-year retrospective review. JAMA Facial Plast Surg 15:226–231Google Scholar
  8. 8.
    Callan P, Goodman GJ, Carlisle I et al (2013) Efficacy and safety of a hyaluronic acid filler in subjects treated for correction of midface volume deficiency: a 24 month study. Clin Cosmet Investig Dermatol 6:81–89CrossRefGoogle Scholar
  9. 9.
    Wortsman X, Wortsman J (2010) Clinical usefulness of variable frequency ultrasound in localized lesions of the skin. J Am Acad Dermatol 62:247–256. CrossRefPubMedGoogle Scholar
  10. 10.
    Wortsman X (2012) Common applications of dermatologic sonography. J Ultrasound Med 31(1):97–111CrossRefGoogle Scholar
  11. 11.
    Wortsman X (2015) Identification and complications of cosmetic fillers: sonography first. J Ultrasound Med 34(7):1163–1172CrossRefGoogle Scholar
  12. 12.
    Costantino A, Fioramonti P, Ciotti M, Onesti MG (2012) Lipofilling in skin affected by radiodermatitis: clinical and ultrasound aspects. Case report. G Chir 33(5):186–190PubMedGoogle Scholar
  13. 13.
    Wortsman X, Wortsman J, Orlandi C, Cardenas G, Sazunic I, Jemec GBE (2012) Ultrasound detection and identification of cosmetic fillers in the skin. J Eur Acad Dermatol Venereol 26:292–301. CrossRefPubMedGoogle Scholar
  14. 14.
    Wortsman X, Wortsman J (2012) Polyacrylamide fillers on skin ultrasound. J Eur Acad Dermatol Venereol 26:660–661. CrossRefPubMedGoogle Scholar
  15. 15.
    Young SR, Bolton PA, Downie J (2008) Use of high-frequency ultrasound in the assessment of injectable dermal fillers. Skin Res Technol 14:320–323CrossRefGoogle Scholar
  16. 16.
    Grippaudo FR, Mattei M (2010) High-frequency sonography of temporary and permanent dermal fillers. Skin Res Technol 16:265–269PubMedGoogle Scholar
  17. 17.
    Schelke LW, Van Den Elzen HJ, Erkamp PP, Neumann HA (2010) Use of ultrasound to provide overall information on facial fillers and surrounding tissue. Dermatol Surg 36(suppl 3):1843–1851CrossRefGoogle Scholar
  18. 18.
    De Lorenzi C (2013) Complications of injectable fillers, part I. Aesthet Surg J 33:561–575CrossRefGoogle Scholar
  19. 19.
    De Lorenzi C (2014) Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J 34:584–600CrossRefGoogle Scholar
  20. 20.
    Dayan SH (2013) Complications from toxins and fillers in the dermatology clinic: recognition, prevention, and treatment. Facial Plast Surg Clin North Am 21:663–673CrossRefGoogle Scholar

Copyright information

© Italian Society of Medical Radiology 2019

Authors and Affiliations

  • Maria Scotto di Santolo
    • 1
  • Candida Massimo
    • 1
  • Giovanni Tortora
    • 2
  • Valeria Romeo
    • 1
  • Michele Amitrano
    • 1
  • Arturo Brunetti
    • 1
  • Massimo Imbriaco
    • 1
  1. 1.Department of Advanced Biomedical SciencesUniversity of Naples Federico IINaplesItaly
  2. 2.Department RadiologyAOS dei colli Monaldi- Cotugno–CTONaplesItaly

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