Imaging Features and Complications of Facial

Cosmetic Procedures
Andrea Meneses Soares de Sousa, MD • Angelo Chelotti Duarte, MD • Marcos Decnop, MD • Daniel de Faria Guimarães, MD
Carlos Alberto Ferreira Coelho Neto, MD • Maíra de Oliveira Sarpi, MD • Luis Gustavo Palhiari Duarte, MD • Soraia Ale Souza, MD, PhD
Larissa Freire Segato, MD • Julia Diva Zavariz, MD • Suresh K. Mukherji, MD, MBA • Márcio Ricardo Taveira Garcia, MD
Author affiliations, funding, and conflicts of interest are listed at the end of this article.

Facial aesthetic procedures have become increasingly popular and

complex, making knowledge of facial anatomy crucial for achiev-
ing desired outcomes without complications. Some of the most
common procedures include blepharoplasty, bichectomy, face-lifts,
facial implants, thread lifting, and fillers. Blepharoplasty and bi-
chectomy are surgical procedures that respectively aim to restore
youthful contours to the periorbita and create a slimmer lower face
by removing Bichat fat from the maxillofacial region. Facial im-
plants are used for aesthetic augmentation of the skeletal structure
and restoration of facial contour by using biomaterials or autoge-
nous bone grafts. Face-lift surgeries involve incisions and removal
of excess skin, and thread lifts involve less invasive procedures
performed by inserting threads beneath the skin, with the aim
to lift the skin and thus reduce wrinkles and sagging. Fillers
improve wrinkles and loss of facial volume, with biologic
types made from animal, human, or bacterial sources (such
as hyaluronic acid), while synthetic fillers include sub-
stances such as paraffin, silicone, calcium hydroxyapatite,
polymethylmethacrylate microspheres, polyacrylamide hydrogel,
hydroxyethyl–ethyl methacrylate, and poly-l-lactic acid. Synthetic
fillers can be classified as rapidly resorbable (<12 months), slowly
resorbable (<24 months), or permanent. Imaging modalities such
as US, CT, and MRI can help identify and analyze each type
of facial aesthetic procedure or filler, as well as their possible
complications such as foreign-body granuloma, noninflammatory
nodule, late intermittent persistent edema, filler migration, infec-
tion, or complications after removal of the buccal fat pad.
©
RSNA, 2023 • radiographics.rsna.org

Introduction
The American Academy of Facial Plastic and Reconstructive
Surgery (AAFPRS) 2021 member survey reported increased
consultations despite COVID-19 concerns because of im-
proved resource savings (89%) and flexible recovery time re-
lated to remote or hybrid work settings (92%). Influenced by
the enduring “Zoom effect” (1), individuals are increasingly
inclined to alter their appearance before rejoining “in-person”
society after a prolonged reliance on video interactions and
filtered social media exposure (1). The majority of AAFPRS

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RadioGraphics 2023; 43(12):e230060
https://doi.org/10.1148/rg.230060
Slide Presentation Content Codes: CT, MR, NR
Abbreviations: BFP = buccal fat pad, CHA = cal-
Quiz questions cium hydroxyapatite, FBG = foreign-body granu-
for this article are loma, FDA = U.S. Food and Drug Administration,
HA = hyaluronic acid, PLLA = poly-l-lactic acid,
available through
the Online PMMA = polymethylmethacrylate, SOOF = sub-
Learning Center. orbicularis oculi fat pad, 3D = three dimensional
TEACHING POINTS
„ Having a thorough knowledge of the anatomy of facial fat compartments and
the vascular network is paramount in the realm of aesthetic procedures to
ensure optimal outcomes and reduce the risk of complications.
„ While autogenous bone grafts have been the standard, they have drawbacks
such as unpredictable resorption and donor site morbidity, prompting the use
of alloplastic facial implants made from biomaterials such as premolded sil-
icone implants, which offer advantages including shorter surgery time and
long-term predictability.
„ The cosmetic use of fillers can improve wrinkles and loss of facial volume.
Common injection sites include the perioral area, periocular region, nasolabial
folds, malar fat pad, marionette lines (vertical wrinkles between the mouth and
chin), glabella, and lips.
„ Facial fillers, implants, and grafts are often seen at routine CT and MRI, inci-
dentally or when these modalities are used to assess complications. CT and
MRI can be used to evaluate the extent and location of the filler, as well as its
relationship to adjacent anatomic structures.
„ FBG can show postcontrast enhancement and fat stranding around the gran-
uloma at the filler site on MR images. In addition to these findings, FBG may
show punctate or eggshell classifications on CT images. FBG can include al-
tered patterns and many different alterations at Doppler US evaluation, indic-
ative of inflammation in the surrounding tissue.
members (83%) reported that 75% or more of their work is in
the field of facial plastic surgery.
The aging process for each individual is unique and de-
pends on the interaction between their genetics and the en-
vironmental factors. Aging facial skin has more significant
cosmetic importance compared with that of other less visible
areas. Collagen loss, chronic sun exposure, and other factors
such as smoking, systemic disease, and air pollution cause a
decrease in skin turgor and elasticity (2). The descent of the
soft tissues of the forehead and atrophy of the buccal fat pad
(BFP) begin in the 3rd to 4th decades of life and are accentu-
ated with the resorption of facial bone, which occurs between
the 6th and 7th decades of life. As a result, persons between
the ages of 30 and 70 are the most common demographic for
elective procedures. Women still represent most patients.
However, the number of cosmetic procedures in men has in-
creased over the years (1).
Anatomy
Having a thorough knowledge of the anatomy of facial fat
compartments and the vascular network is paramount in the
realm of aesthetic procedures to ensure optimal outcomes
and reduce the risk of complications. Understanding the in-
tricate organization and distribution of facial fat compart-
ments allows precise targeting and sculpting, resulting in
natural-looking results. By appreciating the interconnect-
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de Sousa et al
edness of the facial vasculature and its regional variations,
practitioners can take appropriate measures to preserve
blood flow, minimize the risk of ischemia, and promote suc-
cessful healing.
The fat compartments are organized into specific layers
on the basis of their location and function and contain mus-
cular, vascular, and nervous structures (Fig 1). Superficial fat
compartments beneath the skin, including the malar fat pad
(infraorbital fat, superficial medial cheek fat, and nasolabial
fat), lateral temporal-cheek fat, superior jowl fat, and inferior
jowl fat (Fig 2), contribute to facial volume and appearance.
Changes in their volume or distribution can significantly im-
pact facial fullness. The malar fat pad is triangular and located
in the cheekbone area, while the lateral temporal-cheek fat
can be divided into upper and lower compartments with dis-
tinct structures (3). The upper temporal compartment con-
tains no relevant structures, while the lower temporal com-
partment contains the zygomaticotemporal branches of the
trigeminal nerve maxillary division, the frontal branches of
the facial nerve, and the temporal part of the sentinel vein (4).
The sentinel vein is characterized by the most anterior branch
of the superficial temporal vein. It earns its name owing to its
critical role as a dependable and easily identifiable landmark
during surgical procedures and serves to prevent injuries to
the facial nerve (5).
The deep fat compartments are located beneath the mus-
cles responsible for facial expression. These compartments
include the deep medial cheek fat, buccal fat, and suborbi-
cularis oculi fat pad (SOOF) (Fig 3). These fat compartments
provide structural support to the facial muscles and other soft
tissues and play a crucial role in facial aging. The SOOF is
in the lower eyelid and contributes to the smooth transition
between the lower eyelid and the cheek, while the BFP in the
midcheek area provides roundness to the cheeks (6).
Facial retaining ligaments composed of fibrous bands sup-
port and prevent sagging of facial soft tissues, including the
zygomatic and masseteric ligaments, mandibular septum,
and orbicularis retaining ligament. The zygomatic and mas-
seteric ligaments, located in the cheek area, attach to the skull
bone and support the malar fat. The mandibular septum sep-
arates the BFP from deeper structures of the face and provides
support to the lower cheek area by attaching to the bone of the
mandible. The orbicularis retaining ligament, located in the
lower eyelid region, supports the SOOF pad by attaching it to
the orbital bone, preventing sagging or outward bulging (3,4).
The facial arterial blood supply varies in pattern and
depth across faces, originating from the external carotid ar-
tery (ECA) and internal carotid artery (ICA), with the ECA
supplying viscerocranium structures and the ICA perfusing
neurocranium structures. Anastomoses, particularly through
the ophthalmic artery pathway in the forehead and glabella
complex, ensure collateral circulation and show strong con-
tributions between the ECA and ICA, while interconnected
deep and superficial fascial vascular plexuses with perforators
span the face (7). Areas with prominent anastomoses between
ECA and ICA branches, such as the forehead, glabella, nose,
temple, tear trough, and nasolabial fold, pose the highest risk
for vascular complications (8).
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December 2023 de Sousa et al

Figure 1. Anatomic evaluation of the temporal, malar, and preparotid regions. (A) Longitudinal US image in the temporal
region shows the superficial fat layer, deep fat layer, and temporalis muscle, which are distinctly separated by the superficial
(black arrow) and deep (white arrow) fascias. (B) Transverse US image of the malar and preparotid regions demonstrates the
BFP (also referred to as Bichat fat), masseter muscle, and parotid gland.

Figure 2. Three-dimensional (3D) CT reconstruction illustrates

the superficial fat compartments of the face. The malar fat pad
encompasses the infraorbital fat (A), superficial medial cheek
fat (B), and nasolabial fat (C). Additionally, the middle cheek
fat (D), lateral temporal-cheek fat (E), superior jowl fat (F), and
inferior jowl fat (G) are shown.
Figure 3. 3D CT reconstruction shows the deep fat
compartments of the face. The visualization highlights
the medial SOOF (1) and lateral SOOF (2), along with
the deep medial cheek fat (3) and the buccal fat (4).

Types of Procedures
Facial cosmetic procedures have become increasingly popular
in recent decades, making it important to be familiar with the
main types of interventions currently performed, as well as
the way they appear on diagnostic imaging studies.
sues caused by insufficient bone structure. The use of facial
implants to reduce the appearance of expression lines is less
common today, primarily due to the availability of alternative
techniques such as botulinum toxin injections and the endo-
scopic brow lift (10).

Facial Implants Malarplasty.—The loss of malar contour during aging leads to

Facial implants, used for skeletal structure augmentation and
restoring facial contour, are often used in multiple locations si-
multaneously to achieve a harmonious outcome (9,10). While
autogenous bone grafts have been the standard, they have draw-
backs such as unpredictable resorption and donor site morbid-
ity, prompting the use of alloplastic facial implants made from
biomaterials such as premolded silicone implants, which offer
advantages such as shorter surgery time and long-term predict-
ability (9). The malar eminence, chin, mandibula, and nasal
dorsum are commonly targeted sites for these implants (9,6).
Browplasty.—The procedure of placing facial implants in the
forehead (browplasty) is used to address facial contouring is-
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an aged appearance, which can be addressed through malar
implants (malarplasty) to restore cheek volume. These im-
plants are commonly placed intraorally on the anterior wall
of the maxilla (submalar), on the superior and lateral aspect
of the malar prominence (malar), or a combination of both
approaches (9,10).
Rhinoplasty.—Facial implants are also used in cosmetic rhi-
noplasties to augment volume and achieve enhanced facial
harmony. In augmentation rhinoplasty, implants are fre-
quently positioned on the nasal dorsum, tip, and columella.
Autologous and alloplastic implants are used with favorable
outcomes in these procedures (10).
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Cheiloplasty.—The lips, similar to the malar region, undergo
a loss of volume and anterior projection with aging, thus
requiring various facial implants made of autogenous and
alloplastic materials. Among these materials, an expanded
fibrillated polytetrafluoroethylene polymer (Gore-Tex; WL
Gore & Associates) has gained popularity among plastic sur-
geons owing to its biocompatibility, flexibility, and softness.
However, lip augmentation is currently mainly achieved
through fillers (10,11), which are discussed in the “Fillers”
section.
Mentoplasty.—Chin augmentation, also known as mento-
plasty, is used to correct congenital deformities such as man-
dibular retrognathism, as well as deformities resulting from
previous surgeries or trauma. The anteroposterior relation-
ship between the chin and the lower border of the lower lip is
the primary aesthetic criterion considered during procedural
planning. Alloplastic grafts are favored in recent mentoplas-
ties owing to their superior long-term predictability (9,10).
Blepharoplasty
Blepharoplasty, a popular cosmetic procedure in the United
States, aims to restore youthful contours to the periorbita and
midface by removing excess skin, fat, and muscle. Upper and
lower blepharoplasty differ in objectives, techniques, and com-
plications (12), with upper blepharoplasty addressing the upper
lid fold and ptosis, while lower blepharoplasty focuses on cor-
recting orbitomalar deformities (13,14). Careful preoperative
evaluation and individualized planning (6,12) can help prevent
most complications in blepharoplasty. For upper blepharo-
plasty, common complications include lagophthalmos, asym-
metries, and postoperative ptosis. Lower blepharoplasty may
lead to notable complications such as strabismus, rounding of
the lateral sulcus, and overexcision of periorbital fat (6).
Bichectomy
BFP excision, or bichectomy, is a commonly performed pro-
cedure to slim the lower face by removing Bichat fat located
bilaterally in the maxillofacial region. However, scientific ev-
idence that supports its long-term efficacy is limited (14,15).
The Bichat fat is closely related to facial structures (Fig 1B)
such as the parotid gland duct, facial nerve branches, and vas-
cular structures, which are prone to postoperative complica-
tions. MRI is recommended for detecting inadvertent injuries
during surgery, and imaging findings provide valuable infor-
mation for potential corrective measures and to address asym-
metries resulting from such injuries (14,16).
Face-lift
A face-lift is a cosmetic surgical procedure that aims to im-
prove the visible signs of aging in the face and neck. It in-
volves tightening and lifting the skin and underlying tissues
to reduce wrinkles, sagging, and other signs of facial aging.
The procedure typically involves making incisions around the
hairline, temples, and ears to access the underlying tissues
and remove excess skin. Face-lifts are commonly performed
to rejuvenate the appearance of the face, restore facial con-
tours, and achieve a more youthful and refreshed look (17).
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de Sousa et al
These procedures do not require imaging examinations for
their planning or monitoring unless there are complications
such as hematomas, nerve injuries, skin necrosis, or infec-
tions (18).
Fillers
Facial fillers are medical devices used to enhance a person’s
appearance without providing any health benefit (19). Over
the past few decades, the use of fillers has become one of the
most common dermatologic procedures, particularly among
middle-aged women seeking facial rejuvenation (20). These
procedures are occasionally used for nonaesthetic purposes,
such as correcting volumetric soft-tissue loss in lipoatrophy
due to HIV infection, Parry-Romberg syndrome, and postsur-
gical and posttraumatic conditions (21,22).
The cosmetic use of fillers can improve wrinkles and loss
of facial volume. Common injection sites include the perioral
area, periocular region, nasolabial folds, malar fat pad, mari-
onette lines (vertical wrinkles between the mouth and chin),
glabella, and lips (Fig 4).
Due to the high demand for these products, different types
of fillers have been created (23). Injectable facial fillers are
classified on the basis of their properties, such as their nature,
the time interval for biodegradation, and whether they are
composed of one or more materials (24,25).
Fillers can be classified as autologous, biologic, or synthetic
depending on their origin. Autologous fillers use the patient’s
own fat, while biologic types are derived from animals (bo-
vine or porcine), humans, or bacteria (hyaluronic acid [HA]).
Synthetic fillers include paraffin, silicone, calcium hydroxyap-
atite (CHA), polymethylmethacrylate (PMMA) microspheres,
polyacrylamide hydrogel, hydroxyethyl–ethyl methacrylate,
and poly-l-lactic acid (PLLA; Sculptra) (25). Fillers can also
be classified as rapidly resorbable (<12 months), slowly re-
sorbable (<24 months), or permanent (25) (Table 1).
Autologous Fat Fillers.—Autologous fat, an early and safer in-
jectable filler, has advantages such as no hypersensitivity re-
actions or granuloma formation, but complications including
fat necrosis should be considered (23,26). Its use has declined
owing to inconsistent resorption rates, but it remains the safest
option for treating scars and malformations in children (27)
(Fig 5).
Collagen Fillers.—Collagen is a vital component of skin, and
bovine collagen was the first U.S. Food and Drug Adminis-
tration (FDA)–approved injectable dermal filler for scars and
wrinkles in 1981 (28). Human bioengineered and porcine col-
lagens gained popularity for their low risk of hypersensitivity
reactions and received FDA approval in 2008. Collagen fill-
ers typically last for 6–12 months, while collagen mixed with
PMMA microspheres may last up to 5 years (29,30).
Calcium Hydroxyapatite.—CHA (Radiesse; Merz) is composed
of spherical microparticles with a bonelike composition that
are suspended in an aqueous sodium carboxymethyl cellu-
lose gel and has been FDA approved since 2006 for wrinkles
and lipoatrophy (28). The microparticles break down over
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Figure 4. Common injection sites of facial fillers shown in a 75-year-old woman. Axial (A, B) and coronal (C) fat-suppressed T2-weighted MR images show
high-signal-intensity filler material in the malar fat pad (arrows in A), lips (arrowheads in B), and nasolabial folds (white arrow in C) and perioral region (yellow
arrow in C).
Table 1: Types of Fillers and Mode of Absorption
Rapidly resorbable (<12 mo)
HA
Collagen
Autologous fat
Slowly resorbable (<24 mo)
PLLA
CHA
PAAG
Dextran
Permanent
PMMA
Silicone
Paraffin
Note.—PAAG = polyalkylimide and polyacrylamide.
3–6 months, and the volumizing effect may last for 1–2 years.
However, the soft-tissue volume gain that persists even after
the filler is completely reabsorbed suggests that in vivo colla-
gen formation occurs through a fibroblastic response (23,26).
The dynamic areas of the face (lips and the periorbital area)
should be avoided to reduce the prevalence of nodules and
clumps (31,32).
Poly-l-lactic Acid.—PLLA is a biodegradable synthetic
polymer suspended in sodium carboxymethylcellulose and
mannitol and has been used to treat lipoatropy due to HIV
infection and to correct rhytids. PLLA was approved by the
FDA in August 2004 for the treatment of facial lipoatrophy in
patients with HIV infection and is also used for facial rejuve-
nation (28). PLLA microparticles induce subclinical inflam-
mation, leading to collagen synthesis (types I and III) up to
8–24 months after injection (collagen synthesis) (33). It has a
gradual onset of action, and results last for a few years (34).
HA Fillers.—HA, a widely used filler, is favored for its safety
profile. It is a naturally occurring polysaccharide found in
healthy soft tissue and provides intercellular stability by
binding collagen to elastic fibers (23). It has been FDA ap-
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de Sousa et al
proved for cosmetic use since 2003 (35), and HA fillers are
typically cross-linked to extend their half-life. They can be co-
hesive (monophasic) or noncohesive (biphasic) gels based on
cross-linking levels. Injected HA binds with water, combines
with natural HA, and stimulates collagen formation. The re-
sulting volume can last several months to a year (36,37). Hyal-
uronidase injections can rapidly reverse HA fillers (28).
Polymethylmethacrylate.—PMMA microspheres can be in-
jected into the deep dermis or subcutaneous space. These
microspheres are nondegradable, making them stable, per-
manent, and irreversible, and are usually suspended in a solu-
tion that contains bovine (cow) collagen (38). PMMA is the
only permanent dermal filler that is FDA approved (in 2006)
for augmentation of nasolabial folds (39). Although PMMA
is easy to implant, it is difficult to remove, and its nondegrad-
ability poses safety risks (38).
Polyalkylimide and Polyacrylamide Hydrogels.—Polyalkylim-
ide and polyacrylamide (PAAG) is a nonbiodegradable synthetic
material used as a filler for soft-tissue augmentation. It stimu-
lates the accumulation of fibroblasts and macrophages, result-
ing in the formation of a fibrous capsule (23,40). While lacking
FDA approval for dermatologic and cosmetic use (23,41), it is
commonly preferred for patients who are HIV positive with
compromised immune systems, as it carries a lower risk of
granuloma formation and offers satisfactory cosmetic out-
comes. Complications may involve migration and local in-
flammation (23,42).
Silicone Oil Filler.—Silicone oil is a permanent filler that re-
stores volume and induces new collagen synthesis. Although
pure silicone oil is considered inert, minimally antigenic, and
noncarcinogenic, its use as a tissue filler has become contro-
versial owing to the reported high prevalence of complica-
tions. Illicit silicone oil is still used as a facial filler in many
parts of the world, despite the associated risks. Removing sil-
icone fillers is challenging, as the hydrophobic material tends
to disperse as droplets in soft tissue, potentially leading to
the formation of silicone granulomas (23,43). The FDA does
not approve the injection of liquid silicone or silicone gel for
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December 2023
wrinkle filling or tissue augmentation anywhere in the body
(19).
Polytetrafluoroethylene.—Since the middle of the 1990s, the
FDA has given expanded polytetrafluoroethylene (Gore-Tex)
approval for facial augmentation, particularly in the glabella,
nasolabial folds, and lips. The substance can be implanted
using tiny needles in the form of threads or microincisions
and has a highly porous structure, making it permanent but
inert. Some Gore-Tex fillers are arranged in a tubular fashion
to encourage tissue ingrowth (28).
Botulinum Neurotoxin A
The most popular nonsurgical aesthetic procedure in the
United States is the injection of botulinum toxin type A
(BoNTA), a substance that causes flaccid paralysis. By inject-
ing BoNTA into the glabella, superolateral orbicularis oculi,
or depressor anguli oris, facial wrinkles can be removed. De-
pending on the dose and place of injection, the BoNTA effect
can continue for 3–5 months. BoNTA injections cause sub-
cutaneous tissue echogenicity to increase at sonography soon
after injection, which causes blurriness at the border between
the subcutaneous and muscle layers (44).
Thread Lifting
Thread lifts are minimally invasive procedures that elevate
and reposition sagging tissues, improving facial contour (45).
To ensure natural results, threads should be positioned along
the face’s natural tension lines in a vertical direction, consid-
ering the gravitational effects of facial aging and ptosis (Fig
6). Thread lifts can be categorized on the basis of absorption
(absorbable or nonabsorbable), the presence of barbs, and the
direction of threads (unidirectional or bidirectional) (45). Ex-
amples of absorbable threads include polydioxanone threads,
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de Sousa et al
Figure 5. Autologous fat grafting
in a 33-year-old woman with Par-
ry-Romberg disease. (A, B) Pretreat-
ment axial CT image (A) and 3D
reconstruction (B) show right facial
hemiatrophy that is characterized
by thinning of the soft tissues in the
malar and perimandibular regions
(arrow in A). (C, D) Posttreatment
axial CT image (C) and 3D recon-
struction (D) show the restoration
of soft-tissue volume in these areas
and improvement of facial symmetry
due to the autologous fat graft (ar-
row in C).
silhouette soft threads (PLLA), and fine threads with bidirec-
tional absorbable cones (46). Nonabsorbable threads include
APTOS threads, contour threads, silhouette lift threads, and
Woffles threads (polypropylene) (Table 2). Cogged threads,
usually made of polydioxanone, are used for short sutures
(47). Threads can also be classified by size, with short sutures
being shorter than 90 mm and long sutures longer than 90
mm (45). Short sutures are typically used for rejuvenation
and mild aging signs, while long sutures are preferred for
cases that require a more notable lifting effect (45).
Types of Materials and Imaging Evaluation
Facial fillers, implants, and grafts are often seen at routine CT
and MRI, incidentally or when these modalities are used to
assess different types of complications (29). CT and MRI can
be used to evaluate the extent and location of the filler, as well
as its relationship to adjacent anatomic structures.
Implants and Grafts
CT and MRI are imaging methods indicated for the evalua-
tion of implants and cosmetic grafts, as they better indicate
the material’s relationship with adjacent bone structures. Fur-
thermore, biologic materials such as fat, the musculoaponeu-
rotic system, bone, and cartilage maintain their usual tissue
characteristics at CT and MRI.
Silicone implants are well defined and have high homoge-
neous attenuation on CT images (Fig 7) and very low signal
intensity on T1- and T2-weighted MRI images (29). Chemical
shift artifacts are frequently observed in breast silicone im-
plants and intraocular silicone oil used for treatment of ret-
inal detachment. These artifacts are not usually observed in
silicone facial implants, probably owing to their compacted
form (Fig 8). At US, silicone implants are well defined and
anechoic, even in breast implants (Fig 9).
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December 2023 de Sousa et al

Figure 6. Coronal maximum intensity projection CT image in a 50-year-old

man shows high-attenuation structures (arrow) consistent with threads from a
prior thread lift procedure.

Table 2: Types and Subtypes of Main Fillers and Lift Threads

Type of Filler or Lift Thread Commercial Names

Collagen biostimulator Sculptra (Galderma; PLLA), Radiesse (CHA), and Rennova Elleva (Ghana R&D; PLLA)
Filler with biostimulator HArmonyCa (Allergan; HA and CHA;), Ellansé (AQTIS Medical BV; PCL)
HA filler (absorbable nonpermanent) Belotero (Merz Aesthetics), Biogelis/Kirialys (Pharmaesthetics), Cientific, e.p.t.q. (Futerman Inter-
national), Hialurox (Hialurox Pharma), Hyalufit (DMC), Juvederm (Allergan), Perfectha (Sinclair
France SAS), Pluryal (MD Skin Solutions), Rennova (Renova Health), Restylane (Galderma),
Revanesse (Prollenium Medical Technologies), Saypha (Croma Pharma), Stylage (Vivacy Labora-
tories), Teosyal (Teoxane), Varioderm (Adoderm GmbH), Yvoire (LG Chem)
Unabsorbable permanent filler Meta-Crill (Metracril; PMMA), Aquamid liquid silicone (Cortura), and AQUAlift (National Center
for Medical Technologies; polyacrylamide hydrogel)
Lift thread i-THREAD (Healux; PDO), Mint Lift (HansBiomed; PDO), Filblock (PDO), Silhouette Soft (Sinclair
IS Pharma; PLLA), MEDiTHREAD (Medithread; PDO)
Note.—PCL = poly-ε-caprolactone, PDO = polydioxanone.

Porous polyethylene (Medpor; Porex) and polytetrafluoro-
ethylene components (Gore-Tex, Teflon [DuPont], Medpor)
are better identified with the CT soft-tissue window because
they demonstrate intermediate attenuation between fat and
water (mean attenuation, 38.7 ± 7.4 HU) (Fig 10) (48). These
materials can develop fibrovascular growth (49) that is best
represented at MRI. At US, polytetrafluoroethylene compo-
nents are recognizable by their shape and are usually seen as
regular hypoechoic bands.
Fillers
Although most facial fillers look similar on CT and MR im-
ages, some features can help distinguish different types of
fillers (49). CHA fillers appear as high-attenuation material
on CT images, with low-to-intermediate signal intensity on
T1- and T2-weighted MR images owing to their calcium con-
tent (23,29,50) (Fig 11). Awareness of the expected appear-
ance following CHA injection will prevent radiologists from
mistaking these findings for calcifications that indicate an
underlying connective tissue disorder such as dermatomyo-
sitis. Most other facial fillers, such as HA, collagen, and poly-
alkylimide and polyacrylamide, have a similar appearance on
MR images, with high signal intensity on T2-weighted images
due to their high water content (23,25) (Figs 12, 13). Silicone
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fillers can be distinguished at MRI if a silicone-only sequence
is performed, and the signal intensity may vary according to
their viscosity and purity (23). The form used is silicone oil,
and it is expected to have high signal intensity on T1-weighted
images. Facial silicone injection may be difficult to depict on
MR images since it is used as microdroplets and because its
off-label use may be kept undisclosed by the patient and/or
requesting physician.
Injectable fillers may exhibit increased uptake at fluorine-
18 fluorodeoxyglucose PET/CT and PET/MRI. However, the
use of these imaging techniques for evaluating fillers is not
recommended because increased uptake can be observed in
patients with and without complications. Moreover, a poten-
tial pitfall arises when the uptake mimics malignant tumors
or infectious processes in different clinical scenarios (23).
US can also be used to assess the extent, location, and na-
ture of dermal fillers, especially in cases with unsatisfactory
responses that are being evaluated for a new procedure or
treatment (51). Different types of fillers may generate distinct
patterns of echogenicity and posterior acoustic artifacts (51).
HA is usually observed as oval formations, predominantly an-
echoic (Fig 14). Although polyalkylimide and polyacrylamide
also manifest with predominant anechoic deposits, normally
larger amounts are seen, and there are echogenic lines within
7 radiographics.rsna.org
December 2023 de Sousa et al

Figure 7. Silicone mental implant in a 34-year-old woman with retrognathia. (A, B) Axial (A) and sagittal (B) CT images show a high-attenuation implant sit-
uated anterior to the mandible in the chin (arrows). Sometimes the implant is slightly lateralized to correct a facial asymmetry, and sometimes lateralization
may be due to trauma and dislocation. (C) 3D reformation shows the implant (arrow) and its position.

Figure 8. Silicone mental implant in a

56-year-old woman with retrognathia. Axial
T1-weighed (A) and T2-weighted (B) MR im-
ages show an implant with very low signal
intensity (arrows). Chemical shift artifacts
are not usually observed in facial implants.

them. PMMA is seen as layers of irregular material, with hy-

Figure 9. Silicone mental implant. Axial US image shows an anechoic
homogeneous structure in the chin region, along the superficial cortex of
the mandible.
perechoic punctiform structures that promote comet-tail arti-
facts (Fig 15). The appearance of CHA varies with the concen-
tration and the time of application. Calcium is hyperechoic
and generates acoustic shadowing on US images (Fig 16).
PLLA is not typically seen on US images.
The most common adverse event is due to the formation
of nodules, which are seen on US images as well-defined
isoechogenic or slightly hypoechogenic lumps. This can oc-
cur when there is no homogeneous integration of the prod-
uct, which accumulates, or by tissue reaction to the material,
with formation of granulomas. The silicone-free oil form has
a “snowstorm” type of a shadow artifact and spreads in all di-
rections. (Fig 17). Nonabsorbable threads and newly applied
absorbable threads are visualized on US images as hypere-
choic regular linear structures that cast a tenuous shadow and
are best visualized by moving the transducer. US evaluation is
especially useful in cases of surface-level placement and in-
fectious complications.

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December 2023 de Sousa et al

Figure 10. Porous polyethylene mandibular implant used for enhancing facial asymmetry in a 56-year-old woman. Axial (A) and coronal (B) CT images
(soft-tissue window) and mandibular reformation (C) show hypoattenuating material located in both perimandibular regions (arrows).

Figure 11. CHA 10 filler at CT of the face in a

26-year-old woman. Coronal soft-tissue window (A)
and axial bone window (B) CT images show
high-attenuation foci that are bilaterally and rela-
tively symmetrically distributed in the perimandib-
ular region (arrows), consistent with CHA filling.
CHA can be seen as linear streaks or clumps, and
the hyperattenuation and calcification aid in distin-
guishing it from other types of facial fillers, which
will only demonstrate calcification if there is an
associated foreign-body reaction.

Figure 12. Facial fillers with nonspecific imaging fea-

tures in two patients who had no symptoms and under-
went imaging for other indications. (A, B) Axial (A) and
coronal (B) CT images of the face show symmetrically
located soft-tissue-attenuation material (arrows) anterior
to the maxillary sinus. (C, D) Axial T2-weighted (C) and
sagittal T1-weighted (D) MR images in a different patient
show a filling material with high signal intensity (C) and
fat suppression and intermediate signal intensity (D)
located anterior to the maxillary sinuses (arrows in
C) and on the nasal dorsum and tip (arrows in D). No
signs of complications were detected at these imaging
examinations.

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December 2023 de Sousa et al

Figure 13. Nonspecific imaging features of PLLA facial filler in a 43-year-old man with no symptoms. (A) Axial CT image shows material with soft-tissue at-
tenuation in the malar and zygomatic regions (arrows). (B, C) Axial T1-weighted (B) and T2-weighted fat-suppressed (C) MR images show the material with in-
termediate and high signal intensity (arrowheads), respectively. The imaging features of PLLA are similar to those of other types of facial fillers. It is important
for patients to provide a specific clinical history for proper correlation and interpretation of imaging findings.

Figure 14. HA filler at US. US image shows measurement
markers that demarcate the diameters of a typical HA deposit
within one of the facial fat compartments. This deposit is char-
acterized by homogeneous and anechoic content, exhibiting
regular and well-defined boundaries, with no indications of
alterations in the echotexture or echogenicity of the surround-
ing planes.
Figure 15. PMMA filler at US. US image shows the longitudinal extent
of a typical subcutaneous deposit of PMMA within the face (arrows). This
deposit is characterized by hyperechoic content, irregular contours, and
a posterior acoustic reverberation artifact known as a comet-tail artifact
(arrowheads). This artifact significantly limits the visualization and charac-
terization of deeper structures below the deposit.
US or serve as the primary modality for suspected com-
plications in deep soft tissues, beneath bony structures, or
when there is a need to assess inflammatory or infectious
complications.

FBG, Noninflammatory Nodule, and Persistent

Complications
Complications after cosmetic procedures can be diverse and
easily diagnosed clinically, including immediate hypersensi-
tivity, pain, swelling, or tenderness at the filler sites; tempo-
rary blepharoptosis or eyebrow ptosis (after botulinum toxin
type A [BoNTA] injection); face-lifting overcorrection; over-
filling; skin necrosis; and skin discoloration. Most of these
complications are transient and focal, necessitating only a fol-
low-up evaluation (52). However, certain complications such
as infections, nodular formation, foreign-body granulomas
(FBGs), implant rejection, and vascular and neural complica-
tions leading to tissue necrosis and scarring may require im-
aging for accurate diagnosis and appropriate treatment (52).
The choice of imaging method depends on factors such as
method availability, radiologist expertise, and the suspected
complication. US is cost-effective and can provide valuable
information at initial evaluation, especially when performed
in the doctor’s office. CT, MRI, or PET/CT can complement
Volume 43 Number 12
Intermittent Delayed Edema
FBG and noninflammatory nodule (NIN) may exhibit some
similar clinical characteristics, but they differ in terms of
imaging and histopathologic features (53), and it is crucial
to differentiate the two for appropriate patient management
and treatment.
NIN can arise due to poor injection technique resulting
in excessive material being introduced into an area, and it
manifests as a palpable or visible nodule that is typically
harder and whiter than granulomas at clinical analysis. NIN
usually appears within 1–2 months after the procedure and
is histologically characterized by a dense cluster of foreign
material, a few macrophages, occasional giant cells, and a
fibrous pseudocapsule (54,55).
FBG is a rare nonallergic chronic granulomatous reac-
tion to injectable aesthetic materials and occurs in approxi-
mately one in 100 to one in 5000 individuals (56). It is more
commonly associated with nonabsorbable materials, but the
10 radiographics.rsna.org
December 2023 de Sousa et al

Figure 16. CHA at US. US image shows CHA deposits,

which typically manifest as tiny iso- or hyperechoic foci
interspersed within the subcutaneous layer (*). The
presence of posterior acoustic shadowing may some-
times draw more attention during assessment than the
actual deposit location, making the identification of this
artifact a valuable tip in detection of these deposits.

Figure 17. Silicone (oil form) at US. US images show silicone deposits (*) along their longitudinal extent. Silicone deposits typically
exhibit hyperechoic areas with blurred and poorly defined contours permeating the surrounding region. These deposits have the
propensity to migrate within the vertical or horizontal planes of the skin and subcutaneous tissue, even extending into the dermis
(arrow in B) and to distant locations. These deposits impede the assessment of tissues located beneath them by inducing pro-
nounced posterior acoustic shadowing, characterized by echogenic foci in the upper regions, thus giving rise to the visual impres-
sion of a "snowstorm" artifact.

use of polydioxanone and HA has also been linked to FBG
formation (57). Histologically, FBG is composed of inflam-
matory nodules around foreign material particles, abun-
dant macrophages, fibroblasts, and giant cells. It typically
appears between 6 and 24 months after the injection but can
occur even years later (58). Clinically, patients with FBGs
may experience uncomfortable tension, persistent or tran-
sient edema, erythema, or purplish pigmentation, as well
as pain, swelling, and functional impairment. Currently it
is not possible to predict which patients are at risk, as the
reasons for developing a granuloma are still unknown.
FBG can show postcontrast enhancement and fat strand-
ing around the granuloma at the filler site on MR images
(59) (Fig 18). In addition to these findings, FBG may show
punctate or eggshell classifications on CT images (54). FBG
can include altered patterns and many different alterations
at Doppler US evaluation, indicative of inflammation in the
surrounding tissue.
According to multiple authors, FBG is typically treated
with intralesional corticosteroid injection, systemic steroid
therapy, and occasionally surgical excision (23). In contrast,
NIN requires surgical excision and does not respond to in-
tralesional or systemic steroid therapy. In some cases, im-
aging examinations may be requested to better locate these
alterations.
Filler Migration
Filler migration occurs when filler material moves from
the original injection site to other areas of the body, lead-
ing to asymmetry and other aesthetic issues (Fig 19). Fillers
can migrate through lymphatic or hematogenous routes,
and this is a common indication for evaluation with MRI
(29,60). Thinner and more liquid fillers, such as HA, are
more prone to filler migration, which can result from im-
proper injection techniques, a high volume of filler injec-
tion, injection under pressure, massaging the filler, gravity,
lymphatic spread to distant locations, intravascular injec-
tion, muscle activity, or facial movement.
At CT and MRI, the migrated material will exhibit the
same characteristics as at the original site. However, it can
be accompanied by other complications such as FBG or sim-
ulate other diseases like tumors, vascular malformations, or
infectious lesions (61,62).
The popularity of fillers has led to more reports of
blindness caused by intravascular injections of various
materials such as HA, silicone oil, bovine collagen, PMMA,
CHA, and PLLA. HA is frequently reported in connection
with this adverse event, possibly because it is commonly
used in high-risk areas like the glabella, nasolabial fold,
temple, nose, and frontal area. The anastomoses of the
superficial temporal artery with the supraorbital artery

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December 2023 de Sousa et al

Figure 18. FBG in the left middle cheek fat in a 59-year-old woman. (A, B) Coronal (A) and axial (B) postcontrast T1-weighted MR images show a nodule with
postcontrast enhancement (arrow) surrounded by densification of adipose tissue. (C) Axial T2-weighted MR image shows that the filler material is present in
larger quantities than expected and is characterized by low signal intensity (arrow).

Figure 19. Filler migration in a 45-year-old woman. Coronal (A) and axial (B) noncontrast CT images and 3D volume-rendered reconstruction (C) show CHA
migration from subcutaneous fat to the parotid regions and left medial pterygoid muscle (arrows in A and B).

explain why the temple is a high-risk region (52). When
arterial occlusion is suspected, immediate MRI is indicated
(63). The use of hyaluronidase demonstrates a reduction
in vascular complications associated with HA fillers when
administered promptly, preferably within the initial 4-hour
time frame, but it does not appear to offer any advantages if
injected after 24 hours (64).
Infection
Procedures that disrupt the natural cutaneous barrier carry the
risk of infection, which can manifest as early or late compli-
cations. Improper skin asepsis can introduce microbial agents,
including Staphylococcus spp, Propionibacterium acnes, and
nontuberculous mycobacteria, leading to superficial or deep
infections (23,65). While early infections can be clinically di-
agnosed, deeper cellulitis may require imaging evaluation to
assess extension and identify possible associated abscesses. At
imaging, a facial abscess following filler or thread-lifting proce-
dures appears as a fluid collection with restricted diffusion on
MR images and as rim enhancement after intravenous contrast
agent administration on CT and MR images, surrounded by fat
stranding and enhancement that indicate cellulitis. However,
infected fluid collections may not exhibit restricted diffusion
(23,29) (Figs 20, 21).
Late infections are believed to be associated with the colo-
nization of cosmetic materials by a cluster of microorganisms
(bacteria, protozoa, or fungi) within a polymeric matrix called
a biofilm. These biofilms can become activated, leading to ab-
Volume 43 Number 12
scess formation, inflammatory nodules, or systemic infections.
Biofilms are also associated with the development of FBGs
(58,66), but currently no imaging method can be used to di-
rectly diagnose biofilms. The treatment of biofilms is challeng-
ing, as bacteria within the biofilm can evade immune defenses,
rendering antibiotic therapy less effective. Hyaluronidase can
aid in breaking down the biofilm matrix formed by HA gel (67).
Additional treatment options for biofilms include extended use
of antibiotics, intralesional administration of 5-fluorouracil,
and intralesional laser therapy using a 532-nm or 808-nm la-
ser (68). A combination of antimicrobial therapy with a quino-
lone and a third-generation macrolide is recommended (68).
In cases of infection and persistence of biofilm after antibiotic
therapy, surgical removal of nonabsorbable fillers may be nec-
essary (53).
Complications after BFP Removal
Complications after intraoral removal of the BFP include occa-
sional undesirable aesthetic outcomes and damage to import-
ant local structures, which include the buccal branch of the
facial nerve (BBFN) and the Stensen duct (SD) (69). The buc-
cal extension of the BFP has different anatomic interrelations
with the BBFN and the SD. According to Hwang et al (69), the
BBFN may cross superficial to the buccal extension of the BFP
(73.7%) or through it (26.3%), while the SD runs superficial to
(42.1%), deep to (26.3%), or above (31.6%) the buccal extension
of the BFP. Therefore, the intraoral removal technique is more
likely to injure a BBFN by piercing the BFP, leading to perioral
12 radiographics.rsna.org
December 2023
Figure 21. Abscess after HA injection. Color Doppler flow US image
shows a heterogeneous painful nodule with internal septa. Peripheral vas-
cularization is visualized (arrowhead). The surrounding fat demonstrates
increased thickness and hyperechogenicity, indicating an inflammatory
process.
muscle weakness. Similarly, surgical damage to the SD deep to
the BFP can cause salivary obstruction or extravasation in cases
of stenosis or laceration, respectively (Fig 22). It is important
not to misdiagnose salivary fluid retention with hematoma,
which is a complication related to injury of the lower bucci-
nator branch of the facial artery. When there is clinical doubt,
percutaneous aspiration of the swelling cheek will confirm the
diagnosis of sialocele if amylase levels are greater than 100 000
U/L (71).
Volume 43 Number 12
de Sousa et al
Figure 20. Bilateral facial abscesses after HA injections.
(A, B) Axial T1-weighted (A) and T2-weighted fat-sup-
pressed (B) MR images show loculated fluid collections in
the periparotid subcutaneous fat bilaterally (white arrows)
and in the facial process of the right parotid gland (yellow
arrow in B). (C) Axial fat-suppressed T1-weighted MR
image shows rim enhancement after gadolinium-based
contrast agent administration (arrowheads) and slight fat
stranding around the fluid collections, findings consis-
tent with abscesses. (D) Axial diffusion-weighted image
shows fluid collections on the right side with high signal
intensity (arrow), representing restricted diffusion due to
the high viscosity and cellularity of pus (note the absence
of this finding in the fluid collection on the left side).
Conclusion
With the increasing popularity and affordability of facial cos-
metic procedures, it is imperative for radiologists to have a
thorough understanding of facial anatomy, including the su-
perficial and deep adipose compartments, as well as the various
materials used in these procedures. This knowledge is critical
for identifying the expected changes that result from aesthetic
interventions and for detecting any associated complications
at imaging. Accurate recognition of these complications facil-
itates timely treatment, which maximizes the chance of a good
outcome.
Author affiliations.—From the Department of Radiology, Head and Neck Sec-
tion (A.M.S.d.S., M.D., C.A.F.C.N., M.d.O.S., L.G.P.D., S.A.S., J.D.Z., M.R.T.G.)
and Neuroradiology Section (A.M.S.d.S.), Dasa/Alta Excelência Diagnóstica,
Av Juruá 548, Alphaville, Barueri, São Paulo 06455-010 SP, Brazil; Depart-
ment of Radiology, Neuroradiology Section, Irmandade da Santa Casa de
Misericordia de Sao Paulo, São Paulo, Brazil (A.C.D., D.d.F.G.); Division of
Head and Neck Imaging, Instituto Nacional do Cancer, Rio de Janeiro, Bra-
zil (M.D.); Head and Neck Radiology Section, Universidade Federal de São
Paulo, São Paulo, Brazil (S.A.S.); Head and Neck Radiology Section (S.A.S.)
and Ultrasound Section (J.D.Z.), Universidade de São Paulo, São Paulo, Bra-
zil; Department of Dermatology, Universidade de Brasília, Brasília, Bra-
zil (L.F.S.); and Department of Radiology, ProScan Imaging, Cincinnati,
Ohio (S.K.M.). Presented as an education exhibit at the 2022 RSNA Annual
Meeting. Received March 21, 2023; revision requested April 25 and received
June 16; accepted June 23. Address correspondence to A.M.S.d.S. (email:
andreameneses7@gmail.com).
Disclosures of conflicts of interest.—The authors, editor, and reviewers have
disclosed no relevant relationships.
13 radiographics.rsna.org
December 2023 de Sousa et al

Figure 22. Complications after BFP

removal in a 33-year-old woman. Ax-
ial T2-weighted fat-suppressed MR
images show stenosis and dilatation
of the Stensen duct (arrow in A), as
well as salivary extravasation (sia-
locele) resulting from Stenson duct
laceration (arrowhead in B).

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