A Multimodal Ultrasound Assessment Framework for Suspected Vascular Compromise Following Hyaluronic Acid Filler Injection: A Retrospective Six-Patient Case Series

Abstract Background Vascular compromise remains one of the most feared complications following hyaluronic acid (HA) filler injection because delayed recognition may result in cutaneous necrosis, permanent scarring, and, in rare cases, irreversible visual loss. Although current international consensus recommendations advocate immediate recognition and treatment, diagnosis continues to rely predominantly on clinical findings such as blanching, pain, delayed capillary refill, livedoid skin change and evolving tissue ischaemia.1−3 These features may overlap considerably with venous congestion, needle-related trauma, inflammatory oedema and post-procedural ecchymosis, during the acute phase.4 High-frequency ultrasound has emerged as an important adjunct for identifying residual filler, evaluating facial vascular anatomy and guiding specific intervention.5−9 Objectives To describe a retrospective six-patient case series illustrating the role of multimodal ultrasound in patients referred with suspected vascular compromise following HA filler injection, and to propose a structured ultrasound assessment framework including grayscale imaging, color Doppler, power Doppler and spectral Doppler. Methods Six consecutive patients had a comprehensive ultrasound assessment using high-frequency linear transducers. Examinations incorporated grayscale evaluation of soft tissues, localization of residual filler, vascular mapping with color and power Doppler, spectral Doppler interrogation of relevant facial arteries, contralateral comparison and ultrasound-guided hyaluronidase where indicated. Clinical presentation, hemodynamic findings, intervention and follow-up outcomes were retrospectively reviewed. Results Multimodal ultrasound differentiated preserved arterial patency, localized hemodynamic disturbance, residual filler deposition and uncomplicated post-procedural bruising across multiple facial regions. Spectral Doppler provided complementary hemodynamic information when reviewed alongside anatomical localization, color and power Doppler findings and serial reassessment rather than as a standalone diagnostic test. Conclusions High-frequency ultrasound, incorporating grayscale imaging, color Doppler, power Doppler, plus spectral Doppler, provides a thorough imaging strategy for evaluating suspected filler-related vascular events. This case series proposes a practical multimodal assessment framework that may assist clinical decision-making while recognising that prospective validation remains necessary.