Researchers Develop Recommendations for Hyaluronic Acid Filler Placement in Cases of Hollowness, Volume Deficits

The use of ultrasound guidance when placing hyaluronic acid fillers in cases of facial hollowness or volume deficits enhances application safety, according to recommendations published in the Journal of Cosmetic Dermatology.¹

Researchers reported that when ultrasound guidance was used in a cohort of Asian patients, it served as an additional safety measure during soft tissue augmentation in the forehead, upper eyelids, and temples. Its use may be considered in the prevention and management of adverse events associated with filler placement, they noted.

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Background and Methods

Ultrasound-guided filler injection is gaining recognition among dermatology clinicians for its ability to improve procedural safety and enhance aesthetic outcomes. The approach leverages real-time imaging to navigate the anatomy of the face and ensure accurate filler placement, minimizing the risk of complications.²

In the case of a study published in Archives of Plastic Surgery,³ researchers found that the use of doppler ultrasound detection effectively aided in the detection of superficial facial arteries and improved hyaluronic filler placement. Its use also mitigated more serious adverse events, such as vascular complications.

In the present study, researchers from China, Korea, and Thailand worked together to develop practice-based recommendations for the use of ultrasound guidance for upper face fillers.

Their study included both a volunteer patient and cadaver to evaluate safety and technique. Dyed fillers were used in cadaver dissections to analyze injection planes, and experts gathered input through discussions and meetings to refine guidelines for upper-face filler applications. Data collection included photos, videos, and 3D facial analysis.

Anatomical Recommendations

Researchers developed a list of anatomy-based clinical practices for target areas, including the forehead and temple.

Filler injections in the forehead require precision due to the presence of critical vascular structures such as the supraorbital and supratrochlear arteries. Recommendations included:

• Use of a blunt-tip cannula (e.g., 23G or 25G) for filler delivery in the supraperiosteal plane to minimize vascular injury.
• Employing ultrasound to locate and avoid critical vessels.
• Initiating the procedure with local anesthesia and aspirating at the first injection point to ensure safety.
• Adopting the fanning technique for even distribution of 2–5 mL of filler material, adjusted to the patient’s needs.

The temple region is anatomically complex, with critical structures such as the superficial temporal fascia and vessels. Recommendations/techniques for optimal outcomes included:

• Identifying safe injection planes with ultrasound, such as the space between superficial and deep temporal fascia.
• Using a combination of cannula and needle approaches for comprehensive volume restoration and contour smoothing.
• Considering the use of 0.5–1.0 mL filler in microbolus injections for severe volume loss.
• Avoiding scarring by employing multiple entry ports and massaging the area post-treatment to address irregularities.

Recommendations for Clinicians

Experts also devised a list of generalized recommendations for clinicians to improve filler placement safety.

1. Incorporate Ultrasound-Guided Mapping: Use this technique to reduce adverse effects and improve procedural safety. Devices with ≥12 MHz frequency are essential.
2. Understand Upper Facial Anatomy: Master the anatomy of the upper face, including vascular structures and variations, to tailor techniques to individual patient needs.
3. Adopt Advanced Injection Techniques: Utilize ultrasound-guided methods, appropriate tools (eg, blunt cannulas), and safe injection planes for different facial regions to optimize outcomes and mitigate risks.

Conclusions

“Although ultrasound-guided filler placement is still in its infancy and the techniques outlined in this paper are limited to a few cases, current evidence appears promising and may give rise to standard practices incorporating ultrasound in protocols for preventive and therapeutic management of adverse events,” wrote authors Jung et al.

Moving forward, they note that adverse events themselves may be reversed through the use of treatments guided by ultrasound: “Adverse events may be reversed through ultrasonographic-guided treatment (ie, using hyaluronidase).”

The study may have been limited by a lack of existing research on the subject, as well as the practice-based nature of the recommendations. Additionally, there are no existing recommendations or guidelines related to the use of ultrasound guidance when placing filler in other anatomical regions; such guidance may be useful in shaping future guidelines for the upper face.

References

1. Jung JY, Choi H, Han SC, et al. Recommendations on ultrasound-guided hyaluronic acid soft tissue augmentation of the upper face in Asians. J Cosmet Dermatol. 2025;24(1):e16759. doi:10.1111/jocd.16759
2. Haykal D, Cartier H, Yi K, Wortsman X. The transformative potential of AI in ultrasound for facial aesthetics. J Cosmet Dermatol. Published online November 25, 2024. doi:10.1111/jocd.16691
3. Lee W. Hyaluronic acid filler injection guided by doppler ultrasound. Arch Plast Surg. 2023;50(4):348-353. Published 2023 Aug 2. doi:10.1055/s-0043-1770078