Bridging the worlds of radiology and aesthetic medicine.

Thinking about dissolving your dermal filler?  Feeling overfilled or noticing that your features look a bit "off"?  Do you suspect your filler has migrated?  Are you dealing with chronic under-eye swelling?  Or maybe you are simply curious to know if filler injected years ago is still present beneath the skin?

If you don't know the answer - or if you aren't even sure exactly what product was injected into your face - you are not alone.

In the aesthetic world, we encounter this lack of clarity every single day. But as medical professionals, our mantra must be transparency, honesty and patient safety. Our goal should never be to guess or assume. Our goal must be to know.

From Breast Cancer Detection to Aesthetic Precision After more than a decade working as a board-certified radiologist specialising in breast radiology and pelvic MRI, my eyes have been continuously trained. I have spent my career recognising the smallest architectural distortions in human tissue, identifying tiny lesions measuring just a few millimeters, and performing high-precision biopsies under ultrasound guidance.  There is a common misconception that radiologists just stare at computer screens all day. In reality, we also perform biopsies on almost every organ - the breast, thyroid, liver, kidneys, bones etc., and some of them we can perform in real time - in this case, under ultrasound guidance.

When you apply this medical specialty to aesthetic medicine, it becomes some kind of superpower. We aren't just taught anatomy from a textbook; we are trained to read and identify it dynamically on a screen. This allows us to see for example your blood vessels in real time - to avoid them, map your tissue layers, and target misplaced filler with absolute millimetre precision. All that takes practice and experience, not just knowledge.

The Reality of Filler: It Stays Longer Than You Think In my clinical practice, I frequently hear desperate concerns from patients like: - _"Why does my upper face look so much wider now? I only had a little bit of cheek filler years ago..."_ - _"My under-eye area has looked swollen every single morning since a doctor injected me with a 'skinbooster' _(that’s what the doctor told the patient, but actually it was a filler normally used for lips)._"_ - _"I have this weird, bluish tint under my eyes that won't go away."_ - Or just: _"I don’t know what the doctor actually did or injected. He just said that he has a 'great new product' and that it’s perfect for me..."_

Many patients are shocked to learn that dermal fillers - most commonly composed of hyaluronic acid - can easily show up on an ultrasound scan 10 or more years after injection. Furthermore, filler can actually appear larger over time. Because hyaluronic acid is highly hydrophilic (water-attracting), it binds water continuously, which can lead to local or diffuse swelling in the long run.

Fillers can also migrate. A product originally placed deep on the bone to treat a tear trough can gradually shift due to constant muscle movement (and its a thin muscle!) and tissue dynamics, migrating into more superficial layers. The result? Chronic under-eye puffiness or the Tyndall effect (a distorted, bluish tint visible through the skin).

Why "Blind" Dissolving Often Fails A classic history I hear from exhausted patients is "_My previous doctor already tried to dissolve it with Hylase (hyaluronidase - an enzyme used to dissolve hyaluronic acid filler), but it didn't help. I have the feeling it's still there._"

In almost all of these cases, the previous dissolving attempts were done "blindly" - meaning through touch and sight alone, without ultrasound guidance. Just because a previous attempt didn't work does not mean your filler is permanent or impossible to remove.

Modern dermal fillers are highly sophisticated; they use varying manufacturing technologies and possess different rheological properties (levels of stiffness and elasticity). Studies show us that how a filler behaves when exposed to hyaluronidase can be somewhat unpredictable. Some stiff, highly cross-linked fillers cannot simply be dissolved by "flooding” the area with Hyaluronidase. They require a direct, targeted strike or more than one session of dissolving. On an ultrasound screen, these fillers look like distinct, dark pockets or bubbles within the tissue (very similar to cysts).

So sometimes these filler accumulations are quite obvious on the screen. However, some filler pockets are very small (like from a droplet technique), and for an untrained eye, those can be incredibly subtle and easily missed.

When you attempt to pierce one of these stiff filler pockets with a needle without visual guidance, the pocket can simply slide away from the needle tip. Without a live image screen, how can an injector be certain they actually entered the pocket? They can't. Only ultrasound provides that visual confirmation, ensuring the enzyme is delivered precisely where it needs to go.

Safety is a Detailed Consultation It is important for patients to understand that hyaluronidase is an enzyme, not just a simple saline solution. It comes with its own risks, including potential allergic reactions, especially for individuals with known allergies to wasp or bee stings. Hylase can also temporarily dissolve a small amount of your skin's own native hyaluronic acid. Fortunately, your body naturally restores its own native hyaluronic acid very quickly - typically within 20 hours, according to clinical studies. Because dissolving can cause temporary swelling, volume shifts, or minor asymmetries, a second follow-up session can be necessary. This is why a detailed and honest consultation before the procedure is an absolute necessity.

The ultimate takeaway? In modern aesthetics, we no longer have to just guess.  By bringing the diagnostic precision of ultrasound into the aesthetic room, we can offer our patients the safety, clarity, and the answers they have been desperately searching for - because that is exactly what our patients deserve.

Coming Soon: A Case in Point Recently a patient from abroad, looking for a doctor in aesthetic medicine who performs facial ultrasound, found our clinic and contacted us because of a distressing nerve compression syndrome after she received dermal filler in her cheeks for the first time. She has been suffering since March of this year, and two attempts at dissolving the product (without ultrasound guidance) did not help her.

_Read more about this fascinating case and how we targeted it under ultrasound in Part 2!_

_Dr. Marta Bobkiewicz is based at the Skin Atelier Clinic in Kirchberg, Zurich and is a radiologist specialising in aesthetic facial ultrasound providing evaluation of fillers, facial anatomy and complications._