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Abstract The use of fillers for cosmetic purposes has increased in recent years. Although generally considered safe, fillers are not exempt from complications, including ischemic events. Arterial ischemia is a rare but potentially serious complication that requires prompt recognition and management. Ultrasound-guided hyaluronidase injection is emerging as a precise and effective treatment approach. The authors present a pictorial case series of filler-induced arterial ischemia managed with ultrasound-guided hyaluronidase injections, and systematically review the literature on ultrasound findings, enzyme dosage, time to resolution, and overall effectiveness of this approach. They present 3 cases of filler-induced arterial ischemia in the frontal, nasal, and temporal regions with visible intravascular thrombosis managed with ultrasound-guided intravascular hyaluronidase injections. Additionally, the authors systematically reviewed literature from PubMed/Medline, Scopus, Embase, and Web of Science up to August 2024 to evaluate the effectiveness, dosage, and ultrasound techniques utilized in the ultrasound-guided treatment of vascular complications from hyaluronic acid fillers. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we screened 88 studies, finally including 9 studies after full-text evaluation. Data from these studies, alongside our 3 cases (totaling 83 cases), showed rapid resolution of symptoms and ultrasound abnormalities following ultrasound-guided hyaluronidase injections. Delayed hyaluronidase administration was associated with slower or incomplete recovery, highlighting the importance of early intervention. Ultrasound-guided hyaluronidase injections effectively resolve arterial ischemia caused by filler injections, with early intervention significantly enhancing outcomes. Prompt diagnosis and timely ultrasound-guided intervention should be emphasized in clinical practice. Further large-scale randomized studies are necessary to establish standardized treatment protocols for dosage and timing. Level of Evidence: 3 (Therapeutic)
Azizi et al. (Wed,) studied this question.