Sonographic Outcomes of Cosmetic Procedures

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M u s c u l o s k e l e t a l I m a g i n g • P i c t o r i a l E s s ay Wortsman and Wortsman Sonography of Cosmetic Procedures

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Musculoskeletal Imaging Pictorial Essay

Sonographic Outcomes of Cosmetic Procedures Ximena Wortsman1 Jacobo Wortsman2 Wortsman X, Wortsman J

OBJECTIVE. The purpose of this article is to review the sonographic outcomes of common cosmetic and plastic surgery procedures, taking advantage of recent developments in the field of ultrasound that opened its broad application to dermatologic practice. CONCLUSION. Because cosmetic procedures have increased dramatically in frequency, some procedures are being performed by unauthorized personnel and some agents are being used that are not approved by certifying institutions, leading to complications. Thus, documentation of these procedures is an important proposition.

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Keywords: botulinum toxin (Botox), cosmetic complications, fillers, skin ultrasound, ultrasound DOI:10.2214/AJR.11.6719 Received February 16, 2011; accepted after revision June 1, 2011. 1Department of Radiology, Clinica Servet, Faculty of Medicine, University of Chile, Almirante Pastene 150, Providencia, Santiago, Chile. Address correspondence to X. Wortsman ([email protected]). 2 Department of Medicine, Southern Illinois University

School of Medicine, Springfield, IL. WEB This is a Web exclusive article. AJR 2011; 197:W910–W918 0361–803X/11/1975–W910 © American Roentgen Ray Society

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n recent years, there has been explosive growth in surgical and nonsurgical cosmetic procedures, with an increase of 147% from 1997 to 2009 in the United States alone according to the Website of the American Society of Aesthetic Plastic Surgeons (ASAPS) to a total of 10 million [1]. Simultaneously, reports of complications of cosmetic procedures have also been on the increase, mentioned in more than 100 publications in 2009 according to the Website of PubMed [2]. Furthermore, most cosmetic procedures are performed without imaging guidance, reports of standing imaging protocols are practically nonexistent, and follow-up with imaging studies is rarely considered. Thus, when complications do develop, there may not be timely recognition or they may remain undertreated because of attempts to prevent compounding of the problem by avoiding the additional sequela of a skin biopsy. Advances in ultrasound technology for soft tissues have resulted in widespread use in dermatologic conditions and musculoskeletal disorders, with machines that have multichannel capabilities and high-frequency probes (≥ 15 MHz) [3]. In this article, we examine the sonographic outcomes in cosmetic procedures and characterize the complications observed. Technical Considerations All the cases included in this article were obtained from the database of the Department of Radiology of Clinica Servet, Santiago, Chile (a reference center for dermato-

logic ultrasound), over the period from 2001 to 2009. The patients included had been referred by dermatologists or plastic surgeons for ultrasound examination, and the examinations had been consistently performed by the same radiologist using the same technique. The review included only cases with cosmetic procedures confirmed by independent surgical or histologic evidence (total, 364 cases). The ultrasound machines used were models HDI 5000 and IU 22 (Philips Healthcare) and MyLab XV70 Gold and Twice (Esaote Biomedica), with probes of variable frequency, ranging from 7 to 18 MHz. The institutional review board of Clinica Servet exempted this review from the requirement of informed consent. All patients had been examined according to the Helsinki principles of medical ethics. Nonsurgical Procedures Botulinum Neurotoxin A Injection of botulinum toxin type A (BoNTA), a flaccid paralysis-inducing agent, is the most common nonsurgical aesthetic procedure in the United States. BoNTA is used for the removal of facial lines through injections in the glabella, superolateral orbicularis oculi, or depressor anguli oris. The BoNTA effect lasts from 3 to 5 months depending on dosage and injection site [4]. On sonography, immediately after injection, glabellar BoNTA injections produce an increase of subcutaneous tissue echogenicity with resulting blurriness at the margin between the subcutaneous and muscle layers (Fig. 1).

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Sonography of Cosmetic Procedures Cosmetic Fillers Cosmetic fillers are biodegradable or nonbiodegradable (synthetic) biologically inert nanoparticles (1–100 nm in size) injected to fill wrinkles or cutaneous defects. Thus, the commonly used term “dermal fillers” is confusing because the injected material is detected mostly in the subcutaneous tissue. Hyaluronic acid is the main biodegradable filler and usually undergoes complete reabsorption within 3–6 months [5]; in pure formulations it appears sonographically as anechoic round subcutaneous pseudocysts that become smaller over time (Fig. 2). When hyaluronic acid has been mixed with lidocaine, the pseudocysts may show inner echoes (debris). Among the main nonreabsorbable molecules (permanent or synthetic fillers) are silicone (in pure preparations or oily formulations), polymethylmethacrylate, and calcium hydroxyapatite. Pure silicone is anechoic on sonography, similar to its appearance in intact breast implants. Silicone oil, however, is hyperechoic, with a posterior reverberation artifact similar to ruptured breast implants; in the latter probably due to mixing of pure silicone with fatty tissue (Fig. 3). Occasionally, anechoic pseudocysts may appear mingled with hyperechoic areas, depending on the proportions of pure silicone and oily components present in the final formulation. The agent polymethylmethacrylate, used for cosmetic and reconstructive purposes, appears on ultrasound as hyperechoic dots with a minitail reverberation artifact (Fig. 4). Calcium hydroxyapatite, also used in cosmetic and reconstructive procedures, appears sonographically as hyperechoic bands projecting posterior acoustic shadowing [6] (Fig. 5). Complications of filler therapy range from local erythema and swelling to palpable nodules, hyperpigmentation, and fistulous tracts, mimicking common dermatologic diseases, such as morphea or angioedema. In the case of reabsorbable fillers, the reactions are usually transient, disappearing as the agent is reabsorbed [6]. Autologous Fillers Autologous fat—Autologous fat is used to fill wrinkles or for gluteal or breast augmentation through direct injection into the subcutaneous tissue or the muscle itself. On sonography, liquefied fat deposits appear as anechoic round or oval pseudocystic structures, with sometimes increased echogenicity of the subcutaneous tissue or adjacent muscles (Fig. 6). Long-term follow-up may disclose mixed echogenicities and egglike calcifications [7].

Platelet concentrates—Platelet concentrates have been injected locally for the treatment of plantar fasciitis and, most recently, because of supposed healing and rejuvenation properties for removal of nasofold lines [8]. On sonography, there is focal subcutaneous hyperechogenicity suggestive of local edema, or anechoic interlobular fluid collections (Fig. 7). Mesotherapy The term “mesotherapy” refers to natural or synthetic lipolytic factors with an antiaging effect [9] used for treatment of cellulite, aging skin, body contouring, and even hair loss. Neither the mechanism of action nor the efficacy has been established, and the Food and Drug Administration has not approved this treatment modality [10]. On sonography, mesotherapy agents may appear as echoic pseudonodules (related to foreign body granulomatous reaction) sometimes with central anechogenicity (related to liquefaction) (Fig. 8). Testosterone Injections Testosterone injections in both the arms and thighs are most commonly used by body builders [11]. Self-administration or injection by nonmedical personnel to increase muscle size may, however, result in muscle tears within the hypertrophied muscles. The sonographic pattern is characterized by hypoechoic focal linear lesions suggestive of partial thickness tears or hyperechoic areas within the muscles suggestive of edema. Muscle regional blood flow may also be increased (Fig. 9).

ylene (HDPE) structures. Implants come in different configurations: convex or I- or L-shaped [13]. Sonograms of silicone implants (including breasts) consistently show anechogenicity of the device itself and a surrounding hyperechoic linear capsule. HDPE implants, also used in rhinoplasty procedures, appear as hyperechoic bands. Rupture or displacement of the implant may be associated with inflammatory reaction or tissue atrophy that shortens the distance between the dermis and implant (Fig. 11). Acrylic nails consist of a synthetic nondegradable coating attached with glue to the ungual surface covering the nail plates. Artificial nails may induce allergic reactions or interfere with pulse oximetry measurements [14, 15]. Because acrylic nails usually allow transmission of sound waves, they do not alter the sonographic appearance of the nail unit. Thus, the acrylic coating appears as an additional hyperechoic linear structure laid on the normal hyperechoic bilaminar nail plates [16] (Fig. 12).

Tensor Threads Tensor threads or “Russian threads” are nonreabsorbable polypropylene devices, shaped as angled barbed threads or double pointed needles and used for lifting sagging contours in the brow, midface, or neck areas. It is expected that a subsequent fibroblastic reaction will encapsulate the threads enhancing the facial lifting effect. Adverse events have been reported in up to 69% of patients, with 45% early recurrence as well as instances of thread migration or expulsion [12]. On sonography, tensor threads appear as hyperechoic bilaminar structures with bright dots or thorns at the anchoring points (Fig. 10).

Surgical Procedures Liposuction and Abdominoplasty Liposuction refers to the surgical aspiration of fatty tissue from waist, arms, or hips, and abdominoplasty is the actual removal of subcutaneous abdominal fatty tissue, with replacement of the anterior abdominal muscles and reconstruction of the umbilical zone. The procedures are frequently performed in combination, but abdominoplasty, particularly when combined with liposuction of the flanks or in patients severely overweight, has a significant risk of seroma or serohematoma development [17]. The fluid may collect within the abdominal wall close to the incision sites and appears early as predominantly exudate and becomes lymphlike at later stages [18]. On sonography, liposuctioned areas lack hypoechoic fatty lobules, showing instead hyperechoic areas with occasional deposits of anechoic interlobular fluid or even larger collections. Similar anechoic collections may be seen in the adjacent subcutaneous tissue (Fig. 13). Thickening and decreased echogenicity of the sheath of the rectus abdominis muscles are also frequent findings as well as anechoic round-shaped pseudocysts that may represent local fat necrosis.

Body Implants Implants are usually used for augmentation or reshaping of the breast, calf, and buttocks. Smaller implants have been used in the nose, chin, cheek, and jaw. Implants are made of silicone or, less often, high-density porous polyeth-

Blepharoplasty Blepharoplasty involves the removal of excess (sagging) skin from the upper or lower lids; palpebral redundancy is most commonly related to aging or severe exophthalmus. Different surgical techniques are used

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Wortsman and Wortsman to approach the upper and lower lids [19], although excessive skin removal, damage to tarsal structures or orbicular muscles, and occasional orbital abscesses may develop on either site. Sonography allows characterization of extent of skin removal and shows fluid collections or suture loosening (Fig. 14). Rhinoplasty Rhinoplasty, also called “nose reshaping,” is performed for aesthetic or reconstructive purposes. It consists of partial or complete remodeling of the nose and may be combined with chin augmentation to enhance the cosmetic results. Augmentation rhinoplasty, a procedure relatively common in some Asian countries, uses implants of alloplastic materials that include silicone, polyethylene, polyester and polyamide, polytetrafluoroethylene, and hydroxyapatite [20]. Because rhinoplasty involves remodeling of the nasal bones and cartilage, complications include anechoic serohematic fluid collections, loosening of sutures fixing the nasal cartilage, and development of structural irregularities in the nasal cartilage or bones. A late complication of rhinoplasty is the deposition of granulomatous tissue under the dorsum of the nose, altering of the nasal shape and vascularity that may mimic rosacea. On sonography, granulomatous tissue appears hypoechoic, with variable increases in vascularity, whereas bony grafts are hyperechoic and produce acoustic shadowing artifact. Detailed presurgical information on nose anatomy, tumor extension, and cartilage condition can be obtained with ultrasound (Fig. 15). Conclusion Cosmetic procedures are widely performed, but the associated complications may go un-

recognized. In its present iteration, ultrasound can uncover not only anatomic sequels from previous interventions but also current complications when still subclinical. Therefore, the impact of those procedures on cutaneous pathology can be investigated promptly, noninvasively, and in real time. This article may thus provide a conceptual framework for improved care and further research in the rapidly growing area of aesthetic interventions. References 1. American Society of Aesthetic Plastic Surgeons. Statistics. www.surgery.org/media/statistics. Accessed July 13, 2011 2. PubMed Website. Search page. www.ncbi.nlm. nih.gov/Pubmed. Accessed July 13, 2011 3. Wortsman X, Wortsman J. Clinical usefulness of variable frequency ultrasound in localized lesions of the skin. J Am Acad Dermatol 2010; 62:247–256 4. Flynn TC. Botulinum toxin: examining duration of effect in facial aesthetic applications. Am J Clin Dermatol 2010; 11:183–199 5. Bailey SH, Cohen JL, Kenkel JM. Etiology, prevention, and treatment of dermal filler complications. Aesthet Surg J 2011; 31:110–121 6. Wortsman X, Wortsman J, Orlandi C, Cardenas G, Sazunic I, Jemec G. Ultrasound detection and identification of cosmetic fillers in the skin. J Eur Acad Dermatol Venereol 2011 [Epub 2011 Mar 21] 7. Wang H, Jiang Y, Meng H, Zhu Q, Dai Q, Qi K. Sonographic identification of complications of cosmetic augmentation with autologous fat obtained by liposuction. Ann Plast Surg 2010; 64: 385–389 8. Sclafani AP. Applications of platelet-rich fibrin matrix in facial plastic surgery. Facial Plast Surg 2009; 25:270–276 9. Brown SA. The science of mesotherapy: chemical anarchy. Aesthet Surg J 2006; 26:95–98

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10. Atiyeh BS, Ibrahim AE, Dibo SA. Cosmetic mesotherapy: between scientific evidence, science fiction, and lucrative business. Aesthetic Plast Surg 2008; 32:842–849 11. Sinha-Hikim I, Artaza J, Woodhouse L, et al. Testosterone-induced increase in muscle size in healthy young men is associated with muscle fiber hypertrophy. Am J Physiol Endocrinol Metab 2002; 283:E154–E164 12. Rachel JD, Lack EB, Larson B. Incidence of complications and early recurrence in 29 patients after facial rejuvenation with barbed suture lifting. Dermatol Surg 2010; 36:348–354 13. Deshpande S, Munoli A. Long-term results of high-density porous polyethylene implants in facial skeletal augmentation: an Indian perspective. Indian J Plast Surg 2010; 43:34–39 14. Lazarov A. Sensitization to acrylates is a common adverse reaction to artificial fingernails. J Eur Acad Dermatol Venereol 2007; 21:169–174 15. Hinkelbein J, Koehler H, Genzwuerker HV, Fiedler F. Artificial acrylic finger nails may alter pulse oximetry measurement. Resuscitation 2007; 74:75–82 16. Wortsman X, Jemec GB. Ultrasound imaging of nails. Dermatol Clin 2006; 24:323–328 17. Najera RM, Asheld W, Sayeed SM, Glickman LT. Comparison of seroma formation following abdominoplasty with or without liposuction. Plast Reconstr Surg 2011; 127:417–422 18. Andrades P, Prado A. Composition of postabdominoplasty seroma. Aesthetic Plast Surg 2007; 31: 514–518 19. Rousso DE, Brys AK. Extended lower eyelid skin muscle blepharoplasty. Facial Plast Surg 2011; 27:67–76 20. Hong JP, Yoon JY, Choi JW. Are polytetrafluoroethylene (Gore-Tex) implants an alternative material for nasal dorsal augmentation in Asians? J Craniofac Surg 2010; 21:1750–1754

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Fig. 1—Botulinum neurotoxin (Botox, Allergan) injection in 38-year-old woman. A and B, Ultrasound images of glabellar region (transverse views). Before Botox (A), all skin layers have normal appearance. After Botox (B) (uncomplicated, immediately after injection), area injected shows increased echogenicity of subcutaneous tissue and blurry margins between layers. d = dermis, st = subcutaneous tissue, m = epicranius muscle, b = bony margin of skull.

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Sonography of Cosmetic Procedures

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Fig. 2—Cosmetic fillers: Hyaluronic acid injection in 41-year-old woman with swelling of upper lip. A, Ultrasound image (longitudinal view) shows anechoic pseudocysts (ha) in upper lip. Additional finding is presence of hyperechoic areas with reverberation artifact corresponding to unreported silicone oil deposits (asterisks). B, Ultrasound image of left nasofold line (without clinical alterations) shows anechoic pseudocysts of hyaluronic acid (arrows and cursors). d = dermis, st = subcutaneous tissue. Fig. 3—Cosmetic fillers: Ultrasound image (transverse view) of silicone oil injection in 43-year-old woman with frontal swelling shows hyperechoic filler deposits (outline and asterisks) in dermis and subcutaneous tissue. d = dermis, st = subcutaneous tissue.

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Fig. 4—Cosmetic fillers: polymethylmethacrylate injection. A, Ultrasound image of upper lip (longitudinal view) in 29-year-old woman with swelling of upper lip shows hyperechoic filler that produce mini comet-tail artifact (asterisk) within orbicularis oris. d = dermis, om = orbicularis oris muscle. B, Transverse ultrasound image of swollen frontal region in another 65-year-old woman shows dermal hyperechoic deposits with mini comet-tail artifact (asterisk). d = dermis, st = subcutaneous tissue, m = epicranius muscle, b = bony margin of skull.

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Fig. 5—Cosmetic fillers: Ultrasound of left nasofold line (transverse view) of calcium hydroxyapatite injection in 55-year-old woman with local swelling and erythema shows hyperechoic filler deposits (asterisks) that generate posterior acoustic shadowing artifact (AS). d = dermis, st = subcutaneous tissue.

Fig. 6—Ultrasound image (transverse view) of autologous fat injection (uncomplicated) in gluteal region in 41-year-old woman shows anechoic pseudocyst (asterisk) within muscle. d = dermis, st = subcutaneous tissue, m = muscle.

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Fig. 7—Platelet concentrate injection (uncomplicated) in 52-year-old woman. d = dermis, st = subcutaneous tissue, m = muscle. A, Ultrasound image (transverse view) of forearm region obtained before injection on face (testing) shows normal appearance of skin layers. B, Ultrasound image (transverse view) immediately after injection shows areas of increased echogenicity in subcutaneous tissue (asterisks) and blurriness at dermissubcutaneous tissue junction.

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Sonography of Cosmetic Procedures Fig. 8—Mesotherapy (lipolytic injections) complication in 28-year-old woman with erythematous papules on abdomen. e = epidermis, d = dermis, st = subcutaneous tissue. A, Ultrasound image (transverse view) shows round-shaped echoic lesion (cursors) with anechoic center (asterisk) in dermis and superficial subcutaneous tissue. B, Color Doppler ultrasound image shows lesional area is hypovascular (arrows). C, Three-dimensional reconstruction image (5-second sweep) shows lesion (arrows).

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Fig. 9—Testosterone injection complication in 32-year-old man. A, Ultrasound image (transverse view) after erythema and pain in left arm after self-injection of testosterone shows partial tear (1.1 cm) in triceps muscle (hypoechoic line within hyperechoic tissue) (cursors). B, Ultrasound image (transverse view) at high frequency (15 MHz) shows better visualization of tear (cursors). (Fig. 9 continues on next page)

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Fig. 9 (continued)—Testosterone injection complication in 32-year-old man. C, Color Doppler ultrasound image (power Doppler, longitudinal view) shows increased blood flow within lesional area.

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Fig. 10—Tensor threads (complications). A, Drawing of tensor thread shows angled barbed threads (thornlike) (arrows). B, Ultrasound image of right temple region (transverse view) in 49-year-old woman with erythema shows tensor thread in situ. Tensor thread presents hyperechoic bilaminar structure with attached hyperechoic dots that correspond to thorns (arrows). Notice wavy shape of tensor thread with subepidermal location in central segment of image. d = dermis, st = subcutaneous tissue. C, Ultrasound image of left parotid area (transverse view) shows tensor thread reaching into anterior parotid gland (arrows). d = dermis, st = subcutaneous tissue, pg = parotid gland, mm = masseter muscle.

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Sonography of Cosmetic Procedures

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Fig. 11—Silicone implants (uncomplicated). A, Transverse ultrasound image in 57-year-old woman shows chin implant (asterisk) attached to jaw bony margin. d = dermis; st, subcutaneous tissue, b, bony margin of jaw. B, Transverse ultrasound image of tip of nose in 26-year-old woman shows nasal implant between dermis and nasal cartilage (bilobulated structure) (asterisks). d = dermis, c = nasal cartilage.

Fig. 12—Acrylic nail implants (uncomplicated) in 33-year-old woman. Ultrasound image (longitudinal view) shows hyperechoic extra plate (acrylic) laid on top of hyperechoic bilaminar nail plates. a = acrylic nail, pl = nail plates, nb = nail bed, dph = distal phalanx, pnf = proximal nail fold.

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Fig. 13—Liposuction and abdominoplasty in 43-year-old woman. d = dermis, st = subcutaneous tissue. A, Ultrasound image of liposuctioned area (longitudinal view) shows absence of fatty lobules and hyperechogenicity (asterisk) in subcutaneous tissue (as expected). B, Ultrasound image shows complication after abdominoplasty—development of anechoic fluid collection (f) in abdominal wall.

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Fig. 14—Blepharoplasty complication in 62-year-old woman. e = epidermis, d = dermis, st = subcutaneous tissue, b = bony margin of zygomatic process of frontal bone. A, Ultrasound image of upper lid (longitudinal view) shows fluid collection (asterisk) containing hyperechoic band that corresponds to loose suture (arrow). B, Three-dimensional ultrasound image (5-second sweep, transverse view) shows loose suture (arrow) within fluid collection (asterisk).

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Fig. 15—Post-rhinoplasty complications. A, Ultrasound image (transverse view) in 32-year-old man with nasal swelling and erythema shows loose suture (arrowhead) floating in anechoic fluid collection (asterisk). d = dermis, st = subcutaneous tissue. B, Ultrasound image (longitudinal view) at tip of nose in 58-year-old man with postsurgical swelling and erythema shows bony graft (bg) and extensive hypoechoic granulomatous changes (asterisks) within skin. C, Ultrasound image (longitudinal view) at tip of nose in 25-year-old woman with erythema after rhinoplasty and implant of high-density porous polyethylene structure. Hyperechoic implant (p) is being extruded through cutaneous layers, surrounded by hypoechoic granulomatous tissue (asterisk).

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