{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T13:58:24Z","timestamp":1787320704770,"version":"build-2736575974"},"reference-count":38,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2026,5,22]],"date-time":"2026-05-22T00:00:00Z","timestamp":1779408000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background: Vascular adverse events (VAEs) related to facial filler injections are rare but potentially severe complications. Doppler ultrasound has emerged as an adjunct imaging tool for evaluating vascular compromise; however, Doppler findings in facial VAEs remain insufficiently characterized. Objectives: To characterize Doppler ultrasound findings associated with filler-related facial VAEs and to assess whether Doppler patterns differ according to prior hyaluronidase administration. Methods: This international multicenter retrospective observational study included 100 patients with clinically diagnosed facial VAEs following filler injections between May 2022 and April 2025. Doppler ultrasound findings were analyzed, including absent flow in perforators and major arteries, compensatory flow, abnormal waveforms, increased peak systolic velocity (PSV), and absence of Doppler abnormalities. Patients were categorized according to hyaluronidase administration prior to ultrasound evaluation. Descriptive statistics and comparative analyses were performed. Results: One hundred patients (median age, 38 years; IQR: 30\u201350; 88 women) were evaluated. The most frequent Doppler ultrasound findings were absent flow in perforators (42%) and major arteries (35%), followed by compensatory flow (26%), string sign (18%), flow diversion (16%), and increased peak systolic velocity (16%). No Doppler abnormalities were observed in 12% of cases, while tardus\u2013parvus (9%) and staccato waveform (8%) were less frequent. Doppler ultrasound findings did not differ significantly between patients who received hyaluronidase before imaging and those who did not (all p &gt; 0.05). The dose of hyaluronidase varied substantially. Livedo reticularis, blanching, and pain were the most common clinical findings. Central facial arterial territories, particularly the perioral, nasolabial fold, nasal, and glabellar regions, were most commonly involved. Conclusions: Filler-related facial VAEs show recognizable Doppler ultrasound patterns, and the identification of these patterns may improve localization of vascular occlusion and support ultrasound-guided hyaluronidase administration, potentially enabling more targeted delivery with lower doses.<\/jats:p>","DOI":"10.3390\/diagnostics16111587","type":"journal-article","created":{"date-parts":[[2026,5,22]],"date-time":"2026-05-22T16:06:08Z","timestamp":1779465968000},"page":"1587","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Doppler Ultrasound Findings in Filler-Related Facial Vascular Adverse Events: An International Multicenter Study"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5780-4136","authenticated-orcid":false,"given":"Rosa M. S.","family":"Sigrist","sequence":"first","affiliation":[{"name":"Department of Radiology, Hospital das Cl\u00ednicas, School of Medicine, University of S\u00e3o Paulo, S\u00e3o Paulo 05403-010, Brazil"},{"name":"Ultrassonando Clinic, S\u00e3o Paulo 04530-001, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2618-308X","authenticated-orcid":false,"given":"Claudia","family":"Gonzalez","sequence":"additional","affiliation":[{"name":"Highly Specialized Ultrasound Center, Bogota 111121, Colombia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leonie","family":"Schelke","sequence":"additional","affiliation":[{"name":"Department of Dermatology, Erasmus MC University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3359-5023","authenticated-orcid":false,"given":"Ximena","family":"Wortsman","sequence":"additional","affiliation":[{"name":"Department of Dermatology, Faculty of Medicine, Universidad de Chile, Santiago 8380453, Chile"},{"name":"Department of Dermatology, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago 8331150, Chile"},{"name":"Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136, USA"},{"name":"Institute for Diagnostic Imaging and Research of the Skin and Soft Tissues, Santiago 7591018, Chile"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0676-4020","authenticated-orcid":false,"given":"Stella","family":"Desyatnikova","sequence":"additional","affiliation":[{"name":"The Stella Center for Facial Plastic Surgery, Seattle, WA 98101, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fernanda A.","family":"Cavallieri","sequence":"additional","affiliation":[{"name":"Cavallieri Clinic, Rio de Janeiro 22440-040, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7041-3079","authenticated-orcid":false,"given":"Maria Cristina","family":"Chammas","sequence":"additional","affiliation":[{"name":"Department of Radiology, Hospital das Cl\u00ednicas, School of Medicine, University of S\u00e3o Paulo, S\u00e3o Paulo 05403-010, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"4217","DOI":"10.1007\/s00266-024-04260-2","article-title":"Trends in Surgical and Nonsurgical Aesthetic Procedures: A 14-Year Analysis of the International Society of Aesthetic Plastic Surgery-ISAPS","volume":"48","author":"Triana","year":"2024","journal-title":"Aesthetic Plast. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"NP457","DOI":"10.1093\/asj\/sjaa086","article-title":"Incidence of Vascular Obstruction After Filler Injections","volume":"40","author":"Schelke","year":"2020","journal-title":"Aesthetic Surg. J."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Soares, D.M. (2022). Bridging a Century-Old Problem: The Pathophysiology and Molecular Mechanisms of HA Filler-Induced Vascular Occlusion (FIVO)-Implications for Therapeutic Interventions. Molecules, 27.","DOI":"10.3390\/molecules27175398"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1847","DOI":"10.3346\/jkms.2015.30.12.1847","article-title":"Cerebral Angiographic Findings of Cosmetic Facial Filler-related Ophthalmic and Retinal Artery Occlusion","volume":"30","author":"Kim","year":"2015","journal-title":"J. Korean Med. Sci."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1007\/s00266-019-01589-x","article-title":"Fatal Cerebral Infarction and Ophthalmic Artery Occlusion After Nasal Augmentation with Hyaluronic Acid-A Case Report and Review of Literature","volume":"44","author":"Yang","year":"2020","journal-title":"Aesthetic Plast. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1016\/j.jaad.2019.07.032","article-title":"Early ultrasound for diagnosis and treatment of vascular adverse events with hyaluronic acid fillers","volume":"88","author":"Schelke","year":"2023","journal-title":"J. Am. Acad. Dermatol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/j.jaad.2024.02.008","article-title":"Reticulated livedoid skin patterns after soft-tissue filler-related vascular adverse events","volume":"91","author":"Schelke","year":"2024","journal-title":"J. Am. Acad. Dermatol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"674","DOI":"10.1016\/j.anplas.2024.07.012","article-title":"Ultrasound assisted hyaluronic acid vascular adverse event management based on the vascular anatomy","volume":"69","author":"Mojallal","year":"2024","journal-title":"Ann. Chir. Plast. Esthet."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e20230695","DOI":"10.36660\/abc.20230695","article-title":"Recommendation Update for Vascular Ultrasound Evaluation of Carotid and Vertebral Artery Disease: DIC, CBR and SABCV\u20142023","volume":"120","author":"Albricker","year":"2023","journal-title":"Arq. Bras. Cardiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"947","DOI":"10.1016\/j.jvir.2016.03.049","article-title":"Position Statement on Noninvasive Imaging of Peripheral Arterial Disease by the Society of Interventional Radiology and the Canadian Interventional Radiology Association","volume":"27","author":"Dhanoa","year":"2016","journal-title":"J. Vasc. Interv. Radiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"721","DOI":"10.1097\/PRS.0000000000003694","article-title":"The Functional Angiosome: Clinical Implications of the Anatomical Concept","volume":"140","author":"Taylor","year":"2017","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1016\/0007-1226(87)90185-8","article-title":"The vascular territories (angiosomes) of the body: Experimental study and clinical applications","volume":"40","author":"Taylor","year":"1987","journal-title":"Br. J. Plast. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"584","DOI":"10.1177\/1090820X14525035","article-title":"Complications of injectable fillers, part 2: Vascular complications","volume":"34","author":"DeLorenzi","year":"2014","journal-title":"Aesthetic Surg. J."},{"key":"ref_14","first-page":"E61","article-title":"Guideline for the Management of Hyaluronic Acid Filler-induced Vascular Occlusion","volume":"14","author":"Murray","year":"2021","journal-title":"J. Clin. Aesthetic Dermatol."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Wortsman, X. (2018). Guidelines and protocols. Atlas of Dermatologic Ultrasound, Springer International Publishing.","DOI":"10.1007\/978-3-319-89614-4"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1161\/01.STR.31.1.140","article-title":"Specific transcranial Doppler flow findings related to the presence and site of arterial occlusion","volume":"31","author":"Demchuk","year":"2000","journal-title":"Stroke"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"484","DOI":"10.1177\/1358863X20937665","article-title":"Interpretation of peripheral arterial and venous Doppler waveforms: A consensus statement from the Society for Vascular Medicine and Society for Vascular Ultrasound","volume":"25","author":"Kim","year":"2020","journal-title":"Vasc. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"111","DOI":"10.14366\/usg.16054","article-title":"Doppler ultrasonography of the lower extremity arteries: Anatomy and scanning guidelines","volume":"36","author":"Hwang","year":"2017","journal-title":"Ultrasonography"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1002\/ana.410310118","article-title":"The transcranial Doppler appearance of acute carotid artery occlusion","volume":"31","author":"Giller","year":"1992","journal-title":"Ann. Neurol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"852","DOI":"10.1111\/jon.13131","article-title":"Vertebral artery foraminal segment doppler sonography to detect vertebral and basilar artery stenosis or occlusion","volume":"33","author":"Lee","year":"2023","journal-title":"J. Neuroimaging"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"26S","DOI":"10.1016\/j.jvs.2021.04.074","article-title":"The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease","volume":"75","author":"AbuRahma","year":"2022","journal-title":"J. Vasc. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1068","DOI":"10.1161\/01.STR.0000125857.63427.59","article-title":"Vertebral artery occlusion in duplex color-coded ultrasonography","volume":"35","author":"Saito","year":"2004","journal-title":"Stroke"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"354","DOI":"10.1161\/01.STR.7.4.354","article-title":"Noninavasive angiography for the diagnosis of carotid artery disease using Doppler ultrasound (carotid artery Doppler)","volume":"7","author":"Keller","year":"1976","journal-title":"Stroke"},{"key":"ref_24","first-page":"40","article-title":"Doppler Ultrasound in the Management of Vascular Complications Associated with Hyaluronic Acid Dermal Fillers","volume":"15","author":"Munia","year":"2022","journal-title":"J. Clin. Aesthetic Dermatol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"e268","DOI":"10.15557\/JoU.2020.0047","article-title":"Usefulness of Doppler sonography in aesthetic medicine","volume":"20","author":"Jagus","year":"2021","journal-title":"J. Ultrason."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1097\/IOP.0000000000001208","article-title":"Color Doppler Flow Imaging of Retrobulbar Ocular Blood Flow Changes in Retinal Artery Occlusions Caused by Cosmetic Facial Filler Injections","volume":"35","author":"Huang","year":"2019","journal-title":"Ophthalmic Plast. Reconstr. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1097\/DSS.0000000000004842","article-title":"Reviewing the Role of Angiosomes in Filler-Induced Tissue Necrosis: Observed Patterns and Clinical Signs","volume":"52","author":"Myers","year":"2026","journal-title":"Dermatol. Surg."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"2287","DOI":"10.1097\/00006534-200006000-00001","article-title":"The angiosomes of the head and neck: Anatomic study and clinical applications","volume":"105","author":"Houseman","year":"2000","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"185","DOI":"10.4103\/JCAS.JCAS_73_19","article-title":"Importance of Choke Vessels in Injectable Fillers","volume":"13","author":"Jajoria","year":"2020","journal-title":"J. Cutan. Aesthetic Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"818e","DOI":"10.1097\/PRS.0000000000004287","article-title":"The Role of Anastomotic Vessels in Controlling Tissue Viability and Defining Tissue Necrosis with Special Reference to Complications following Injection of Hyaluronic Acid Fillers","volume":"141","author":"Ashton","year":"2018","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"256","DOI":"10.1016\/j.jvs.2018.04.018","article-title":"The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures","volume":"68","author":"Zierler","year":"2018","journal-title":"J. Vasc. Surg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1093\/asj\/sjac227","article-title":"Ultrasound-Guided Targeted vs Regional Flooding: A Comparative Study for Improving the Clinical Outcome in Soft Tissue Filler Vascular Adverse Event Management","volume":"43","author":"Schelke","year":"2023","journal-title":"Aesthetic Surg. J."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"3519","DOI":"10.1007\/s00266-025-04707-0","article-title":"Superior Outcomes with Ultrasound-Guided Hyaluronidase for Impending Filler-Induced Facial Skin Necrosis: A Systematic Review and Pilot Meta-Analysis","volume":"49","author":"Boey","year":"2025","journal-title":"Aesthetic Plast. Surg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1168","DOI":"10.1097\/SCS.0000000000011175","article-title":"Understanding Vascular Complications Arising From Dermal Filler Injection","volume":"36","author":"Yi","year":"2025","journal-title":"J. Craniofac. Surg."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e14285","DOI":"10.1111\/dth.14285","article-title":"Facial vascular danger zones for filler injections","volume":"33","author":"Wollina","year":"2020","journal-title":"Dermatol. Ther."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"592e","DOI":"10.1097\/PRS.0000000000009991","article-title":"Patterns of Filler-Induced Facial Skin Ischemia: A Systematic Review of 243 Cases and Introduction of the FOEM Scoring System and Grading Scale","volume":"151","author":"Soares","year":"2023","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"935","DOI":"10.1016\/j.ophtha.2025.01.020","article-title":"Vision-Threatening Complications of Soft Tissue Fillers: A Report by the American Academy of Ophthalmology","volume":"132","author":"Foster","year":"2025","journal-title":"Ophthalmology"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1145","DOI":"10.1093\/asj\/sjac060","article-title":"Upper Facial Anastomoses Between the External and Internal Carotid Vascular Territories\u2014A 3D Computed Tomographic Investigation","volume":"42","author":"Li","year":"2022","journal-title":"Aesthetic Surg. J."}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/11\/1587\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,27]],"date-time":"2026-05-27T11:24:32Z","timestamp":1779881072000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/11\/1587"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,22]]},"references-count":38,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["diagnostics16111587"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics16111587","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,22]]}}}