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      <h1 class="highwire-cite-title" id="page-title">Imaging of Facial Fillers: Additional Insights</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">D.T. Ginat</span> and <span class="highwire-citation-author" data-delta="1">C.J. Schatz</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">December 2012,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">33 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(11) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E140-E141; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A3394 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-12348--61144324413" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">D.T. Ginat </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Department of Radiology
Massachusetts General Hospital, Harvard Medical School
Boston, Massachusetts</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=D.T.%2BGinat%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Ginat%20D&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AD.T.%2BGinat%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">C.J. Schatz </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>b</span>Beverly Tower Wilshire Advanced Imaging
Beverly Hills, California
University of Southern California Keck School of Medicine
Los Angeles, California</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=C.J.%2BSchatz%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Schatz%20C&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AC.J.%2BSchatz%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div></div></div>  </div>

  
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    <div data-panels-ajax-tab-preloaded="jnl_ajnr_tab_art" id="panels-ajax-tab-container-highwire_article_tabs" class="panels-ajax-tab-container"><div class="panels-ajax-tab-loading" style ="display:none"><img class="loading" src="http://ajnr-stage2.stage.highwire.org/sites/all/modules/contrib/panels_ajax_tab/images/loading.gif" alt="Loading" title="Loading" /></div><div class="panels-ajax-tab-wrap-jnl_ajnr_tab_art"><div class="panel-display panel-1col clearfix" >
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view"><span class="highwire-journal-article-marker-start"></span><p id="p-1">We appreciate the interest that readers have expressed in our article “Imaging Features of Midface Injectable Fillers and Associated Complications,”<sup><a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a></sup> and we are pleased to be regarded as pioneers in the field. However, we would like to clarify a few points and share additional insights on the subject.</p><p id="p-2">Our review article certainly shows the utility of CT and MR imaging for depicting many of the early and late complications associated with facial fillers besides foreign-body granulomas.<sup><a id="xref-ref-1-2" class="xref-bibr" href="#ref-1">1</a></sup> In particular, we have, on occasion, received requests to delineate the extent of filler material, especially when migration has occurred. Indeed, some of these cases are shown in our article.</p><p id="p-3">Although facial fillers may appear different from one patient to another and can change with time (<a id="xref-fig-1-1" class="xref-fig" href="#F1">Fig 1</a>), ), certain fundamental imaging characteristics of facial fillers can be surmised. This is the case in many other areas of radiology in which pattern-recognition applies. Although imaging is not intended simply to differentiate the types of facial filler materials, some of these have rather distinctive appearances.</p><div id="F1" class="fig pos-float odd"><div class="highwire-figure"><div class="fig-inline-img-wrapper"><div class="fig-inline-img"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/33/11/E140/F1.large.jpg?width=800&amp;height=600&amp;carousel=1" title="Axial CT image (A) shows hyperattenuated deposits of calcium hydroxylapatite within the bilateral cheeks (arrows). Axial CT image obtained 22 months (B) later shows significant interval decrease in the hyperattenuated deposits." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-356958500" data-figure-caption="&lt;div class=&quot;highwire-markup&quot;&gt;&lt;div xmlns=&quot;http://www.w3.org/1999/xhtml&quot;&gt;Axial CT image (&lt;em&gt;A&lt;/em&gt;) shows hyperattenuated deposits of calcium hydroxylapatite within the bilateral cheeks (&lt;em&gt;arrows&lt;/em&gt;). Axial CT image obtained 22 months (&lt;em&gt;B&lt;/em&gt;) later shows significant interval decrease in the hyperattenuated deposits.&lt;/div&gt;&lt;/div&gt;" data-icon-position="" data-hide-link-title="0"><span class="hw-responsive-img"><img class="highwire-fragment fragment-image lazyload" alt="Fig 1." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" data-src="http://ajnr-stage2.stage.highwire.org/content/ajnr/33/11/E140/F1.medium.gif" width="440" height="162"/><noscript><img class="highwire-fragment fragment-image" alt="Fig 1." src="http://ajnr-stage2.stage.highwire.org/content/ajnr/33/11/E140/F1.medium.gif" width="440" height="162"/></noscript></span></a></div></div><ul class="highwire-figure-links inline"><li class="download-fig first"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/33/11/E140/F1.large.jpg?download=true" class="highwire-figure-link highwire-figure-link-download" title="Download Fig 1." data-icon-position="" data-hide-link-title="0">Download figure</a></li><li class="new-tab"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/33/11/E140/F1.large.jpg" class="highwire-figure-link highwire-figure-link-newtab" target="_blank" data-icon-position="" data-hide-link-title="0">Open in new tab</a></li><li class="download-ppt last"><a href="/highwire/powerpoint/39118" class="highwire-figure-link highwire-figure-link-ppt" data-icon-position="" data-hide-link-title="0">Download powerpoint</a></li></ul></div><div class="fig-caption" xmlns:xhtml="http://www.w3.org/1999/xhtml"><span class="fig-label">Fig 1.</span> <p id="p-4" class="first-child">Axial CT image (<em>A</em>) shows hyperattenuated deposits of calcium hydroxylapatite within the bilateral cheeks (<em>arrows</em>). Axial CT image obtained 22 months (<em>B</em>) later shows significant interval decrease in the hyperattenuated deposits.</p><div class="sb-div caption-clear"></div></div></div><p id="p-5">Although uncommon, scar formation is a known complication of facial fillers. This phenomenon has been previously described with silicone and Artecoll (Suneva Medical, San Diego, California), for example: “Siliconomas and scarring can occur after a variable delay after the silicone injections, ranging from 3 weeks to a decade. … If Artecoll (collagen and polymethylmethacrylate) is injected too superficially, it can lead to persistent itchiness, redness and even hypertrophic scarring that may need to be reduced by local corticosteroid injections.”<sup><a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a></sup></p><p id="p-6">With regard to the hypermetabolism associated with injection of a calcium hydroxylapatite filler, this can be a source of false-positive findings on PET.<sup><a id="xref-ref-3-1" class="xref-bibr" href="#ref-3">3</a>,<a id="xref-ref-4-1" class="xref-bibr" href="#ref-4">4</a></sup> We have also noted hypermetabolism associated with fillers other than calcium hydroxylapatite (<a id="xref-fig-2-1" class="xref-fig" href="#F2">Fig 2</a>, suggestive of an inflammatory response that can be subclinical.</p><div id="F2" class="fig pos-float odd"><div class="highwire-figure"><div class="fig-inline-img-wrapper"><div class="fig-inline-img"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/33/11/E140/F2.large.jpg?width=800&amp;height=600&amp;carousel=1" title="Axial CT image (A) shows nearly fluid-attenuation filler material within the bilateral cheeks (arrows). PET image (B) shows hypermetabolic foci within the cheek subcutaneous tissues corresponding to reported collagen-based fillers (arrows). However, the patient did not have symptoms related to this finding, and no biopsy was performed." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-356958500" data-figure-caption="&lt;div class=&quot;highwire-markup&quot;&gt;&lt;div xmlns=&quot;http://www.w3.org/1999/xhtml&quot;&gt;Axial CT image (&lt;em&gt;A&lt;/em&gt;) shows nearly fluid-attenuation filler material within the bilateral cheeks (&lt;em&gt;arrows&lt;/em&gt;). PET image (&lt;em&gt;B&lt;/em&gt;) shows hypermetabolic foci within the cheek subcutaneous tissues corresponding to reported collagen-based fillers (&lt;em&gt;arrows&lt;/em&gt;). However, the patient did not have symptoms related to this finding, and no biopsy was performed.&lt;/div&gt;&lt;/div&gt;" data-icon-position="" data-hide-link-title="0"><span class="hw-responsive-img"><img class="highwire-fragment fragment-image lazyload" alt="Fig 2." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" data-src="http://ajnr-stage2.stage.highwire.org/content/ajnr/33/11/E140/F2.medium.gif" width="440" height="169"/><noscript><img class="highwire-fragment fragment-image" alt="Fig 2." src="http://ajnr-stage2.stage.highwire.org/content/ajnr/33/11/E140/F2.medium.gif" width="440" height="169"/></noscript></span></a></div></div><ul class="highwire-figure-links inline"><li class="download-fig first"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/33/11/E140/F2.large.jpg?download=true" class="highwire-figure-link highwire-figure-link-download" title="Download Fig 2." data-icon-position="" data-hide-link-title="0">Download figure</a></li><li class="new-tab"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/33/11/E140/F2.large.jpg" class="highwire-figure-link highwire-figure-link-newtab" target="_blank" data-icon-position="" data-hide-link-title="0">Open in new tab</a></li><li class="download-ppt last"><a href="/highwire/powerpoint/39290" class="highwire-figure-link highwire-figure-link-ppt" data-icon-position="" data-hide-link-title="0">Download powerpoint</a></li></ul></div><div class="fig-caption"><span class="fig-label">Fig 2.</span> <p id="p-7" class="first-child">Axial CT image (<em>A</em>) shows nearly fluid-attenuation filler material within the bilateral cheeks (<em>arrows</em>). PET image (<em>B</em>) shows hypermetabolic foci within the cheek subcutaneous tissues corresponding to reported collagen-based fillers (<em>arrows</em>). However, the patient did not have symptoms related to this finding, and no biopsy was performed.</p><div class="sb-div caption-clear"></div></div></div><p id="p-8">The study of facial fillers is an evolving multidisciplinary field with many questions remaining to be answered.</p><div class="section ref-list" id="ref-list-1"><h2>References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a>

<div class="cit ref-cit ref-journal" id="cit-33.11.E140.1"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Ginat</span>  <span class="cit-name-given-names">DT</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Schatz</span>  <span class="cit-name-given-names">CJ</span></span></li></ol><cite>.
<span class="cit-article-title">Imaging features of midface injectable fillers and associated complications</span>.
<abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr>
<span class="cit-pub-date">2012</span>
<span class="cit-month">Jul</span>
<span class="cit-day">26</span>
<span class="cit-comment">[Epub ahead of print]</span>
</cite></div><div class="cit-extra"></div></div></li><li><span class="ref-label">2.</span><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2. in text" id="ref-2">↵</a>

<div class="cit ref-cit ref-journal" id="cit-33.11.E140.2" data-doi="10.4103/0974-2077.63222"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Lafaille</span>  <span class="cit-name-given-names">P</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Benedetto</span>  <span class="cit-name-given-names">A</span></span></li></ol><cite>.
<span class="cit-article-title">Fillers: contraindications, side effects and precautions</span>.
<abbr class="cit-jnl-abbrev">J Cutan Aesthet Surg</abbr>
<span class="cit-pub-date">2010</span>;
<span class="cit-vol">3</span>:
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<div class="cit ref-cit ref-journal" id="cit-33.11.E140.3" data-doi="10.1017/S0022215108002065"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Damrose</span>  <span class="cit-name-given-names">EJ</span></span></li></ol><cite>.
<span class="cit-article-title">Radiographic properties of injected calcium hydroxylapatite: potential false positive findings on positron emission tomography</span>.
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<div class="cit ref-cit ref-journal" id="cit-33.11.E140.4" data-doi="10.1016/j.crad.2009.05.004"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Feeney</span>  <span class="cit-name-given-names">JN</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Fox</span>  <span class="cit-name-given-names">JJ</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Akhurst</span>  <span class="cit-name-given-names">T</span></span></li></ol><cite>.
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        	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-volume highwire-cite-metadata">Vol. 33</span>, <span  class="highwire-cite-metadata-issue highwire-cite-metadata">Issue 11 </span><div  class="highwire-cite-metadata-pubdate highwire-cite-metadata">1 Dec 2012 </div></div>
      
      
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