Highlight
This study examined 231 patients with palpable indurations after cosmetic filler injections using high-frequency ultrasound (12-18 MHz), achieving an 85.7% concordance rate with pathological findings. Seven lesion types were identified based on sonographic features. Non-hyaluronic acid (non-HA) filler granulomas notably responded better to noninvasive therapy, whereas granulomas without residual filler and HA granulomas favored invasive treatments, which overall resulted in superior clinical improvement.
Background
Minimally invasive cosmetic filler injections have rapidly grown in popularity within aesthetic medicine due to their efficacy and safety profile. However, despite advances, a rising incidence of complications including palpable indurations, nodules, and granulomas has become a clinical challenge. These complications not only impact aesthetic outcomes but also patient satisfaction and safety. Current management strategies lack a standardized diagnostic approach, particularly in differentiating lesion types and guiding treatment choice. High-frequency ultrasound imaging offers noninvasive, real-time assessment of soft tissue alterations, thus holding promise to improve diagnosis precision and treatment tailoring.
Study Design
This retrospective study included 231 patients presenting with palpable indurations post-cosmetic filler injections, collected from January 2023 to June 2025. All patients underwent high-frequency ultrasonography (12–18 MHz) to characterize lesion morphology, echogenicity, and vascularity. Seventy patients also received pathological biopsy to confirm lesion type and to validate ultrasound findings. Lesions were categorized into seven ultrasound-based types correlating with pathological diagnoses. Treatment strategies, either invasive (surgical excision, drainage) or noninvasive (medication, observation), were selected based on ultrasound characterization. Clinical outcomes and treatment efficacy were analyzed, and concordance between ultrasound and pathology was evaluated.
Key Findings
The concordance rate between ultrasound characterization and pathological diagnosis was 85.7%, underscoring high diagnostic reliability of high-frequency ultrasound in characterizing filler-associated indurations. Among complications, non-HA filler accumulations were the most frequent (37.2%), followed by granulomas secondary to non-HA fillers (22.5%).
Therapeutic response differed by lesion type: non-HA filler granulomas showed significantly better responses to noninvasive treatments (P < .001), suggesting that conservative management can be effective in these cases, minimizing morbidity. Conversely, granulomas without residual filler and those associated with HA fillers were more amenable to invasive interventions such as excision or drainage (P = .001), which translated into better resolution of indurations.
Invasive treatment overall demonstrated greater clinical improvement in induration reduction (P < .001), indicating that precise ultrasound-guided therapeutic decisions could optimize outcomes. The study also emphasized the importance of tailored treatment strategies informed by imaging rather than a uniform approach.
Expert Commentary
The utilization of high-frequency ultrasound to differentiate types of filler-related complications represents a significant step forward in aesthetic medicine, integrating precision diagnostics with personalized therapy. The high concordance with pathology supports the reliability of this imaging tool for real-world clinical decision-making. Moreover, by appropriately identifying lesion characteristics, unnecessary invasive procedures can be avoided, thus reducing patient risk and healthcare costs.
Limitations include the retrospective design and the potential for variability in ultrasound operator expertise, which could affect image interpretation. Future prospective trials with standardized ultrasound protocols may enhance the generalizability of findings. Additionally, long-term follow-up data on recurrence rates post-treatment would be valuable.
Conclusion
This study demonstrates that high-frequency ultrasound is a valuable, accurate, and noninvasive modality for diagnosing palpable indurations after cosmetic filler injections, facilitating individualized treatment approaches. By distinguishing lesion types such as residual filler accumulations versus granulomas, clinicians can select appropriate invasive or noninvasive therapies, thereby enhancing patient outcomes and minimizing complications. Standardizing ultrasound evaluation protocols could improve complication management in aesthetic practice and inform clinical guidelines.
Funding and Registration
No specific funding was reported for this retrospective study. The study was conducted in compliance with institutional ethical standards.
References
1. Wang X, Liu FJ, Chen CL, et al. Retrospective Study on Palpable Indurations After Cosmetic Filler Injection: Ultrasonic Characterization and Image-Guided Therapy. Aesthetic Surgery Journal. 2026;46(7):790-798. PMID: 41968101.
2. De Boulle K, et al. Understanding and Managing Filler Complications: A Clinical Guide. Dermatol Surg. 2022;48(1):58-69.
3. Beleznay K, Carruthers JD, Humphrey S, Jones D. Avoiding and Treating Blindness from Fillers: A Review of the World Literature. Dermatol Surg. 2015;41(10):1097-1117.
