Superior Outcomes with Ultrasound-Guided Hyaluronidase for Impending Filler-Induced Facial Skin Necrosis: A Systematic Review and Pilot Meta-Analysis.

Summary

Across four studies (n=55), ultrasound-guided hyaluronidase achieved a pooled complete resolution rate of 94.6% (95% CI 80.6–98.7%) for impending filler-induced facial skin necrosis. Evidence synthesis suggests improved outcomes compared with non-image-guided practices while potentially enabling lower hyaluronidase dosing. The review followed registered methods and graded certainty using GRADE.

Key Findings

• Pooled complete resolution after ultrasound-guided hyaluronidase was 94.6% (95% CI 80.6–98.7%) across 4 studies (55 patients).
• Image guidance has been associated with improved outcomes and lower hyaluronidase doses versus non-image-guided 'flooding' practices.
• Risk of bias was assessed with JBI tools and certainty rated with GRADE; protocol was registered (CRD42024585657).

Clinical Implications

Adopt ultrasound-guided hyaluronidase as first-line for suspected filler-induced ischemia; map vascular compromise, target injections, and consider lower dosing rather than blind high-dose flooding. Build training and protocols for point-of-care facial ultrasound in aesthetic practices.

Limitations

• Only four small observational studies (total n=55); no randomized comparisons
• Heterogeneity in ultrasound protocols, dosing, and timing; publication bias cannot be excluded

Future Directions

Prospective comparative studies and pragmatic trials to define optimal ultrasound protocols, dose–response, and time-to-treatment; development of training standards and reporting guidelines.