Lead
Experts warn that cosmetic dermal fillers can cause dangerous vascular complications after a multi‑center ultrasound review of 100 mishaps found absent blood flow in crucial facial vessels. The study, led by Dr Rosa Sigrist and presented at the Radiological Society of North America annual meeting, examined cases from May 2022 to April 2025 across clinics in Brazil, Colombia, Chile, the Netherlands and the United States. Scans showed loss of flow in vessels that connect superficial and deep facial arteries in just under half the patients and absent flow in major arteries in roughly a third. Investigators and professional bodies now advise wider use of ultrasound to map vessels before injections and to guide targeted treatment if problems arise.
Key takeaways
- Study sample: 100 cases of filler‑related complications were reviewed across six centers in five countries between May 2022 and April 2025.
- Vessel involvement: Ultrasound detected absent flow in superficial‑to‑deep connecting vessels in just under 50% of cases and in major vessels in about 33% of cases.
- Serious outcomes: Vascular occlusion from filler can lead to tissue necrosis, facial deformity and, in rare but severe instances, blindness or stroke when nasal or periocular vessels are affected.
- Clinical recommendation: Investigators recommend pre‑procedure ultrasound mapping and ultrasound‑guided treatment as ways to reduce risk and target hyaluronidase delivery when occlusion occurs.
- Professional stance: The British Association of Aesthetic Plastic Surgeons (BAAPS) says ultrasound use is rising but not yet standard; BAAPS continues to call for tighter regulation of aesthetic injectables.
- Regulatory moves: The UK government has signalled plans for licensing and restrictions on who may perform high‑risk cosmetic procedures, with a public consultation planned for early 2026.
Background
Dermal fillers are injectable products frequently used to soften wrinkles, restore volume and reshape features such as lips and the nose. While generally safe in trained hands, fillers carry a known, uncommon risk of vascular occlusion — the accidental injection of material into or immediately adjacent to a blood vessel. Facial arteries form a complex network in which superficial vessels connect with deeper arterial branches and with vessels that communicate with the eye and brain; this anatomy raises the stakes for injections around the nose and periorbital region. Past case reports and smaller series have documented skin necrosis and, rarely, blindness following inadvertent intra‑arterial injection, prompting growing interest in imaging‑guided techniques.
The study reported at RSNA builds on this clinical concern by applying ultrasound routinely to assess patients after complications and as a planning tool before injections. Ultrasound is non‑ionising, portable and increasingly available in aesthetic and surgical settings, but access and operator training vary widely. Professional societies and regulators have debated how to standardise safety practices for aesthetic procedures, balancing patient access with protection against avoidable harms. The UK government’s consultation on restricting high‑risk cosmetic interventions signals broader policy momentum internationally.
Main event
Researchers led by Dr Rosa Sigrist reviewed 100 cases of suspected filler‑related vascular injury referred to specialised radiology, dermatology and plastic surgery centres between May 2022 and April 2025. Participating centres included two radiology units in Brazil, one in Colombia, one in Chile, a dermatology centre in the Netherlands and a plastic surgery centre in the United States. Patients underwent Doppler and grey‑scale ultrasound to assess arterial flow and the location of filler material relative to vessels. In nearly half of the cases, sonography showed absent flow in small vessels that bridge superficial and deep arterial systems; in about a third it showed absent flow in larger named arteries.
Investigators described ultrasound not only as a diagnostic tool but as a guide for treatment. When occlusion was localised on scan, clinicians could inject hyaluronidase directly at the site under ultrasound guidance rather than relying on broad‑area injections. The team reported that targeted injections used lower volumes of enzyme and allowed more precise reversal attempts, which may limit tissue damage and reduce the need for extensive debridement or reconstructive surgery. Study authors emphasised training and equipment availability as prerequisites for adopting routine pre‑procedure scanning.
The research will be presented at the Radiological Society of North America annual meeting, where authors plan to discuss imaging protocols, case selection and recommended workflows for integrating ultrasound into aesthetic practice. The investigators cautioned that not every injector has access to real‑time ultrasound or the expertise to interpret vascular findings and that wider adoption will require education, certification and updates to clinical guidelines. Professional societies are weighing how to incorporate imaging recommendations into best‑practice frameworks.
Analysis & implications
Clinically, the study underscores that vascular occlusion is not a theoretical risk confined to rare anecdotes: imaging confirmed disturbed or absent flow in a substantial fraction of referred cases. That prevalence among referrals does not translate directly to population incidence of complications, but it highlights that when occlusions occur they frequently involve anatomically important vessels. For injectors, this strengthens the argument for mapping vessel anatomy before procedures in high‑risk zones such as the nose, nasolabial folds and periorbital area.
From a safety systems perspective, ultrasound offers two complementary benefits: pre‑treatment mapping to avoid vessel puncture and post‑event localisation to direct therapy. Targeted hyaluronidase delivery under ultrasound may reduce enzyme exposure while improving outcomes, but robust comparative trials are lacking. Implementing routine ultrasound would also require training standards, quality control and reimbursement models; without those, uptake may remain uneven and patient protection partial.
Regulatory and market implications are significant. If regulators move to require licensed providers and facility standards for higher‑risk procedures, clinics offering injectables may need to invest in equipment and staff training or restrict services to medically qualified personnel. That could improve safety but also reshape access and costs in the aesthetic sector. International differences in regulation and professional oversight mean change may occur unevenly across jurisdictions.
Comparison & data
| Finding | Cases (n=100) | Approx. percentage |
|---|---|---|
| Absent flow in superficial‑to‑deep connecting vessels | Just under 50 | ~48% (just under half) |
| Absent flow in major arteries | About 33 | ~33% (one third) |
The table summarises the primary imaging findings reported by the investigators. The sample consists of referred complication cases, not a consecutive series of all filler procedures, so percentages should be interpreted in that referral context. The numbers indicate that when complications are serious enough to prompt specialist imaging, impaired arterial flow is commonly demonstrable. Further population‑level data would be needed to estimate absolute risks per procedure and to compare outcomes between ultrasound‑guided and unguided practice.
Reactions & quotes
“Ultrasound lets us pinpoint where the occlusion is and target treatment precisely rather than injecting blindly,”
Dr Rosa Sigrist, lead researcher
Dr Sigrist framed ultrasound as both a diagnostic and therapeutic aid, arguing that targeted hyaluronidase under imaging can reduce tissue damage and the need for more aggressive interventions.
“Mapping out the location of blood vessels undoubtedly provides valuable information ahead of treatment,”
Nora Nugent, president, British Association of Aesthetic Plastic Surgeons (BAAPS)
BAAPS echoed the call for imaging and for tighter regulation of who may perform injectables, saying increased oversight could reduce iatrogenic harm and improve patient safety.
Unconfirmed
- Exact population incidence: The study reports imaging findings among 100 referred cases but does not provide a denominator of total procedures, so the true per‑procedure risk of occlusion remains unquantified.
- Comparative efficacy: While investigators describe better outcomes with ultrasound‑guided hyaluronidase, randomised trial data comparing guided versus unguided treatment are not yet available.
- Long‑term outcomes: The dataset covers imaging and acute management; long‑term sequelae rates (functional and cosmetic) after guided versus blind treatment require further follow‑up.
Bottom line
The ultrasound review of 100 filler complications presented at RSNA reinforces that vascular occlusion is a clinically significant hazard of facial fillers, particularly in anatomically sensitive areas around the nose and eye. Imaging frequently demonstrated absent flow in vessels that link superficial and deep arterial systems and in major arteries, findings that can explain the tissue loss and, in severe cases, vision loss reported in some patients.
Adopting routine pre‑procedure vessel mapping and using ultrasound to guide treatment of suspected occlusions could reduce harm, but doing so at scale will require training, standards and likely regulatory changes. Policymakers and professional bodies face choices about licensing, scope of practice and minimum equipment standards that will shape how safely aesthetic injections are delivered going forward.
Sources
- BBC News — news report summarising the study and expert comments (media)
- Radiological Society of North America (RSNA) Annual Meeting — conference where the work was presented (professional conference)
- British Association of Aesthetic Plastic Surgeons (BAAPS) — professional body statement on ultrasound and regulation (professional organisation)