Case and Research Letter
The Utility of Skin Ultrasound for the Diagnosis of Complications of Tissue Filler Materials
Utilidad de la ecografía cutánea en el diagnóstico de las complicaciones por materiales de relleno
D. Menis
, M. Castellanos-González, R. Llamas-Martín, F. Vanaclocha Sebastián
Corresponding author
Servicio de Dermatología, Hospital 12 de Octubre, Madrid, Spain
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A propósito de 2 casos" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1437 "Ancho" => 1801 "Tamanyo" => 327696 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Basal cell carcinoma; image taken before starting treatment. B, Large, indurated plaque with 3 linear elastic elements; image taken 2 months after starting imiquimod treatment. C, The lesion persists, but with reduced erythema.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Márquez García, T. Ojeda Vila, L. Ferrándiz Pulido, J.J. Ríos Martín" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." 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Menis, M. Castellanos-González, R. Llamas-Martín, F. Vanaclocha Sebastián" "autores" => array:4 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Menis" "email" => array:1 [ 0 => "diana.menis@hotmail.it" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Castellanos-González" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Llamas-Martín" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Vanaclocha Sebastián" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital 12 de Octubre, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad de la ecografía cutánea en el diagnóstico de las complicaciones por materiales de relleno" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 668 "Ancho" => 939 "Tamanyo" => 83176 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Siliconomas with a snowstorm pattern. Red arrow, hyperechoic image corresponding to the filler material. Green arrow, posterior acoustic shadow.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The increase in the number of cosmetic procedures in recent years means that in our daily practice we are seeing ever more side effects of the different techniques. One of these is the formation of granulomas secondary to dermal fillers; the etiology of these lesions can be difficult to determine, not only because patients neglect to inform us they have undergone cosmetic treatment or they are unaware of the type of material used, but also because the clinical presentation can be similar to that of certain dermatologic diseases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> When medicolegal issues arise, the most useful additional test is biopsy, as each material presents a specific histologic pattern,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> but this is an invasive technique and patients may sometimes reject such tests. Skin ultrasound is an alternative, non-invasive test that, through specific sonographic patterns, can identify the type of material involved and its exact site.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 52-year-old woman who came to outpatients for multiple asymptomatic lesions on the forehead. The first lesions had appeared in the glabellar region 8 years earlier and had remained stable until the year prior to consultation when, coinciding with the appearance of new lesions, she developed recurrent episodes of inflammation that persisted for several days and resolved spontaneously. Physical examination revealed yellowish-pink plaques of 1-2<span class="elsevierStyleHsp" style=""></span>cm diameter, with well-defined borders, a firm consistency, and a peau d’orange appearance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The only finding of interest in the patient's past history was the injection of a filler material 14 years earlier; she was unable to specify what the material was. On biopsy there were abundant foamy histiocytes suggestive of a histiocytic reaction to the filler material (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Due to the lack of specific findings, we decided to perform skin ultrasound to identify the filler material employed. The study revealed hyperechoic images that had no clearly visible border and that left an acoustic shadow; the images were present in the skin and deeper tissues of the frontal and malar regions and of the chin. The sonographic pattern corresponded to the so-called snowstorm sign (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), which is compatible with a diagnosis of siliconomas. In this case, skin ultrasound enabled us to define the type of material employed and its presence in other areas in addition to those in which the patient stated the injections had been performed. This made it possible to plan management. At the time of writing, the patient had completed 3 months of treatment with isotretinoin, 0.4<span class="elsevierStyleHsp" style=""></span>mg/kg/d, which has led to a partial improvement in the lesions.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">High-frequency ultrasound is a simple and rapid non-invasive technique with a good cost-efficacy relationship. The technique enables us to identify the nature, volume, and site of the injected material. The thickness of the soft tissues does not affect image quality, and the material in question can be identified in 97.5% of cases.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Ultrasound can differentiate between reabsorbable and permanent filler materials, though it cannot distinguish between different materials of the same class. Absorbable materials are seen as anechoic or hypoechoic masses with the appearance of cysts whereas permanent materials produce a hyperechoic pattern; semiabsorbable materials are seen as hypoechoic areas that contain foci of variable echogenicity. Liquid silicone can produce a specific pattern known as a snowstorm pattern because of the presence of multiple hyperechoic collections with an acoustic shadow.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We consider that skin ultrasound can be very useful when filler materials give rise to complications and it can provide a valid alternative for those patients who, for whatever reason, do not wish to undergo biopsy. Ultrasound establishes the clinical diagnosis more accurately than other imaging studies—the presence of a permanent material, such as calcium hydroxyapatite, can give false positive results with magnetic resonance, computed tomography, and positron emission tomography.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In addition, ultrasound can aid decision-taking regarding subsequent treatment as, for example, the presence of a permanent filler material would contraindicate treatment with interferon.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Ultrasound can also help us to orient patients about the prognosis as, in contrast to reabsorbable filler materials, granulomatous reactions to permanent materials are unlikely to resolve in less than 6 months. Furthermore, knowledge of the site and nature of a filler material will make it possible to avoid future complications if further interventions are to be performed at the same site. Finally, some authors consider that ultrasound study improves the patient's awareness of the cosmetic results achieved and, in those patients not convinced of the persistence of an injected material, the ultrasound images can reinforce their perception of the definitive results.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our opinion, although biopsy continues to be the gold standard for the definitive diagnosis of the side effects of an injected filler material, skin ultrasound is a valid and useful alternative diagnostic method in patients who reject invasive diagnostic tests.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Menis D, Castellanos-González M, Llamas-Martín R, Vanaclocha Sebastián F. Utilidad de la ecografía cutánea en el diagnóstico de las complicaciones por materiales de relleno. Actas Dermosifiliogr. 2014;105:797–798.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 670 "Ancho" => 951 "Tamanyo" => 66442 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Yellowish-pink plaques of variable size and with well-defined borders on the forehead.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 716 "Ancho" => 952 "Tamanyo" => 260214 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Skin with abundant foamy histiocytes (some with microvacuoles and others with macrovacuoles) in the reticular dermis, suggestive of a histiocytic reaction to a filler material (hematoxylin-eosin, original magnification ×10).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 668 "Ancho" => 939 "Tamanyo" => 83176 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Siliconomas with a snowstorm pattern. Red arrow, hyperechoic image corresponding to the filler material. Green arrow, posterior acoustic shadow.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Granuloma por silicona líquida" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Rubio-Flores" 1 => "M.A. Martín-Díaz" 2 => "M.J. González-Beato" 3 => "R.M. Díaz-Díaz" 4 => "C. 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Alomar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ad.2012.07.007" "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2013" "volumen" => "104" "paginaInicial" => "920" "paginaFinal" => "923" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22995946" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of high-frequency ultrasound in the assessment of injectable dermal fillers" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.R. Young" 1 => "P.A. Bolton" 2 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 6 | 20 |
| 2024 October | 80 | 47 | 127 |
| 2024 September | 80 | 17 | 97 |
| 2024 August | 119 | 78 | 197 |
| 2024 July | 94 | 43 | 137 |
| 2024 June | 90 | 21 | 111 |
| 2024 May | 65 | 44 | 109 |
| 2024 April | 60 | 20 | 80 |
| 2024 March | 76 | 25 | 101 |
| 2024 February | 66 | 37 | 103 |
| 2024 January | 53 | 36 | 89 |
| 2023 December | 59 | 31 | 90 |
| 2023 November | 51 | 21 | 72 |
| 2023 October | 51 | 23 | 74 |
| 2023 September | 77 | 42 | 119 |
| 2023 August | 58 | 18 | 76 |
| 2023 July | 48 | 30 | 78 |
| 2023 June | 62 | 23 | 85 |
| 2023 May | 70 | 26 | 96 |
| 2023 April | 56 | 33 | 89 |
| 2023 March | 65 | 24 | 89 |
| 2023 February | 40 | 27 | 67 |
| 2023 January | 40 | 24 | 64 |
| 2022 December | 60 | 42 | 102 |
| 2022 November | 36 | 24 | 60 |
| 2022 October | 33 | 37 | 70 |
| 2022 September | 39 | 53 | 92 |
| 2022 August | 63 | 38 | 101 |
| 2022 July | 28 | 34 | 62 |
| 2022 June | 23 | 25 | 48 |
| 2022 May | 40 | 47 | 87 |
| 2022 April | 56 | 46 | 102 |
| 2022 March | 56 | 71 | 127 |
| 2022 February | 50 | 22 | 72 |
| 2022 January | 66 | 44 | 110 |
| 2021 December | 44 | 42 | 86 |
| 2021 November | 53 | 36 | 89 |
| 2021 October | 47 | 59 | 106 |
| 2021 September | 47 | 37 | 84 |
| 2021 August | 39 | 32 | 71 |
| 2021 July | 28 | 34 | 62 |
| 2021 June | 36 | 18 | 54 |
| 2021 May | 32 | 23 | 55 |
| 2021 April | 51 | 64 | 115 |
| 2021 March | 41 | 18 | 59 |
| 2021 February | 61 | 32 | 93 |
| 2021 January | 28 | 7 | 35 |
| 2020 December | 40 | 11 | 51 |
| 2020 November | 26 | 14 | 40 |
| 2020 October | 30 | 13 | 43 |
| 2020 September | 23 | 7 | 30 |
| 2020 August | 16 | 21 | 37 |
| 2020 July | 32 | 21 | 53 |
| 2020 June | 28 | 20 | 48 |
| 2020 May | 31 | 14 | 45 |
| 2020 April | 36 | 13 | 49 |
| 2020 March | 33 | 21 | 54 |
| 2020 February | 6 | 1 | 7 |
| 2019 December | 4 | 2 | 6 |
| 2019 November | 0 | 2 | 2 |
| 2019 September | 4 | 1 | 5 |
| 2019 July | 0 | 2 | 2 |
| 2019 June | 2 | 0 | 2 |
| 2019 May | 1 | 12 | 13 |
| 2019 April | 0 | 10 | 10 |
| 2019 March | 2 | 7 | 9 |
| 2019 January | 1 | 0 | 1 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 5 | 0 | 5 |
| 2018 September | 2 | 0 | 2 |
| 2018 August | 0 | 17 | 17 |
| 2018 July | 0 | 4 | 4 |
| 2018 June | 0 | 5 | 5 |
| 2018 May | 0 | 6 | 6 |
| 2018 April | 0 | 5 | 5 |
| 2018 March | 3 | 3 | 6 |
| 2018 February | 21 | 2 | 23 |
| 2018 January | 36 | 8 | 44 |
| 2017 December | 34 | 7 | 41 |
| 2017 November | 40 | 9 | 49 |
| 2017 October | 29 | 5 | 34 |
| 2017 September | 32 | 14 | 46 |
| 2017 August | 49 | 10 | 59 |
| 2017 July | 45 | 6 | 51 |
| 2017 June | 45 | 8 | 53 |
| 2017 May | 21 | 20 | 41 |
| 2017 April | 19 | 7 | 26 |
| 2017 March | 16 | 11 | 27 |
| 2017 February | 14 | 7 | 21 |
| 2017 January | 19 | 9 | 28 |
| 2016 December | 36 | 8 | 44 |
| 2016 November | 44 | 12 | 56 |
| 2016 October | 38 | 11 | 49 |
| 2016 September | 1 | 6 | 7 |
| 2016 August | 0 | 2 | 2 |
| 2016 July | 13 | 2 | 15 |
| 2016 June | 14 | 0 | 14 |
| 2016 May | 14 | 9 | 23 |
| 2016 April | 11 | 0 | 11 |
| 2016 March | 8 | 8 | 16 |
| 2016 February | 12 | 1 | 13 |
| 2016 January | 8 | 2 | 10 |
| 2015 December | 12 | 3 | 15 |
| 2015 November | 12 | 2 | 14 |
| 2015 October | 5 | 12 | 17 |
| 2015 September | 5 | 3 | 8 |
| 2015 August | 13 | 1 | 14 |
| 2015 July | 32 | 4 | 36 |
| 2015 June | 30 | 3 | 33 |
| 2015 May | 32 | 3 | 35 |
| 2015 April | 7 | 2 | 9 |
| 2015 March | 5 | 2 | 7 |
| 2015 February | 8 | 4 | 12 |
| 2015 January | 8 | 1 | 9 |
| 2014 December | 4 | 3 | 7 |
| 2014 November | 4 | 1 | 5 |
| 2014 October | 10 | 1 | 11 |
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