When the dorsal nasal artery is connected right in the middle of the dorsum of the nose. Right where the doctor wanted to inject the filler!

The world of cosmetic medicine has taken off dramatically over the past few decades. Non-surgical procedures, and in particular the use of injectable hyaluronic acid (HA) fillers, have become an accessible way for many to refine facial contours or combat signs of aging. Although these treatments are generally considered safe, introducing foreign material into the complex anatomy of the face is never entirely without risk. Particularly with filler treatments of the nose, relatively many complications, such as blood vessel occlusions, occur (see photo 2).

[IMAGE02:Photo 2. Vascular Adverse Event of the Nose]

However, recent scientific publications from 2025 mark a crucial turning point in the way physicians approach these treatments. The common thread in these new studies is clear: the use of ultrasound is transforming cosmetic medicine from "blind" injections to millimeter-precision work. In this article, we discuss the latest insights regarding ultrasound, the risks of vascular complications, and how technology offers solutions for long-term problems such as the so-called 'Avatar nose' 

[IMAGE01] The New Standard: The Delphi Consensus on Ultrasound

For a long time, cosmetic physicians relied exclusively on their anatomical knowledge and experience. Although thorough anatomical knowledge is indispensable, the exact location of blood vessels varies greatly from person to person. To ensure safety, an international panel of fifteen experts from eleven different countries (including dermatologists, cosmetic physicians, radiologists, and plastic surgeons) reached a so-called modified Delphi consensus in 2025 regarding the use of ultrasound in filler treatments.

This consensus, led by Dr. Peter Velthuis among others, shows that ultrasound is no longer a luxury, but an essential requirement for safe treatments. The experts agree that physicians must use a linear transducer (the ultrasound probe) with a minimum frequency of 15 MHz. This high frequency is necessary to image the superficial skin layers and the underlying structures with razor-sharp clarity.

In addition, the use of Color Doppler technology has been mandated in the guidelines. This allows doctors to visualise blood flow in the veins and arteries in real time. Especially in high-risk areas such as the nose, experts consider ultrasound mapping of the blood vessels prior to injection to be absolutely necessary. Moreover, should a complication occur, ultrasound is indispensable for diagnosis and targeted treatment.

The danger zone: why the nose The necessity of this ultrasound visualisation becomes painfully clear when we look at the most feared complication with fillers: a Vascular Adverse Event (VAE). This occurs when a filler is accidentally injected into a blood vessel or compresses a blood vessel, blocking the blood supply to the skin. Without prompt intervention, this can lead to necrosis (tissue death), resulting in permanent scarring, and rare complications such as blindness and cerebral ischemia.

A detailed retrospective study by Khoshnaw, Schelke, and Velthuis (2025) analysed 120 patients with documented UAEs between 2019 and 2024. They investigated whether certain parts of the face are more susceptible to severe tissue damage than others. The researchers divided the face into different anatomical zones and compared the medial part (the center of the face, such as the nose) with the lateral part (the sides, such as the temples and cheekbones).

The results were telling: necrotic complications (the most severe stages of a VAE) occurred significantly more frequently in the nasal region. Remarkably, the researchers found no direct link between this necrosis and the distribution of the major facial arteries (such as the branches of the carotid artery). This suggests that local, complex factors—such as the density of small, connecting blood vessels (anastomoses) in the center of the face—play a major role.

In practice, for patients and doctors, this means that treatments around the nose must be performed with the utmost caution. This is precisely where ultrasound proves its value: by mapping the blood vessels in this medial 'danger zone' beforehand, the doctor can drastically reduce the risk of a VAE.

The "Avatar Nose" In addition to acute complications such as VAEs, the popularity of fillers also brings with it long-term challenges. A common misconception is that hyaluronic acid fillers are completely broken down by the body on their own after 6 to 12 months. However, recent research shows that fillers can sometimes remain present in the tissue for years, and in some cases even up to 15 years. A striking phenomenon resulting from this is described in a case study by Lau et al. (2025): the so-called 'Avatar nose'. In non-surgical rhinoplasty, filler is often placed on the bridge of the nose to raise or straighten it (dorsal augmentation).

Although the initial results are often beautiful, the filler can spread or retain fluid over the years. This results in a delayed, unnatural widening of the bridge of the nose, an aesthetic reminiscent of the characters from the famous film ‘Avatar’. Redness of the nose due to vascular compression or hypervascularity can also occur. The study describes patients who suddenly developed this widening years after their last treatment.

Here, too, ultrasound played a key role. Using portable, high-frequency ultrasound equipment, the doctors were able to demonstrate exactly that residues of the old hyaluronic acid filler were still present. Subsequently, the ultrasound was used to very precisely inject hyaluronidase directly into the old filler. This ultrasound-guided treatment proved to be extremely effective.

The unwanted widening disappeared, the natural contours of the nose returned, and the patients experienced no side effects. This underscores an important message: complications or undesirable aesthetic results from the past can nowadays be remedied excellently and minimally invasively, thanks to imaging techniques.

Conclusion and outlook on the future Cosmetic medicine is maturing. Publications from 2025 show a clear shift from a purely aesthetic approach to a medical-scientific approach where patient safety comes first. The integration of ultrasound into the daily practice of the cosmetic physician is one of the most important developments of this decade. It enables practitioners to:

1. Act preventively: Map a patient's unique anatomy and blood vessels to avoid dangerous injections in the face (particularly the high-risk nasal region).

2. Intervene accurately: In the event of an unexpected vascular complication, immediately identify the location of the blockage and resolve it adequately.

3. Address long-term problems: Detect old, migrated fillers (such as in the Avatar nose) and dissolve them with extreme precision using hyaluronidase.

For anyone considering a cosmetic treatment with fillers, there is a clear, reassuring message: the technology and knowledge to perform these procedures safely are better than ever today.

As a patient, it is therefore entirely legitimate- and even advisable- to ask the cosmetic doctor whether they use ultrasound. With the right expertise and the right equipment, the beautiful results of cosmetic injectables can go hand in hand with the highest standard of medical safety.