We’re here to enhance beauty!

AUTHOR:

Dr Barbara Parda

aesthetic and regenerative medicine doctor, psychiatrist

The safety of aesthetic procedures depends on many factors. What should we pay particular attention to in order to avoid complications when using hyaluronic acid and – increasingly popular – biostimulators? Is ultrasound in aesthetic medicine clinics a trend or a necessity?
Explains Barbara Parda-Głomska, MD, aesthetic and regenerative medicine doctor, author of Facial Ultrasound 1:1 training programs and group courses, and masterclass trainer at Beautyeurope.eu in ultrasound-guided poly-L-lactic acid treatments.

We are here to enhance our patients’ beauty. Therefore, as physicians, we must do everything possible to minimize the risk of complications and, if they occur, to manage their consequences effectively. For patients, treating complications means not only high financial costs but also significant physical and psychological distress.

The safety of procedures depends on multiple factors, with proper patient qualification being fundamental. However, most complications arise from poor technique and/or the use of unreliable products.

Technique Above All

For several years, I have been treating complications, and since incorporating ultrasound and closely following the scientific literature, I can confidently say—along with leading global experts—that around 80% of late-onset nodules result from poor technique.

Additionally, many injectors use products of unknown origin, often unlicensed. Patients coming from non-medical clinics frequently present complications caused not only by insufficient knowledge of anatomy and technique but also by low-quality products.

In the case of hyaluronic acid, I repeatedly encounter specific brands associated with complications such as widespread immune responses—painful, hard, migrating nodules affecting not only the treated area but the entire face.

The literature also describes ASIA syndrome (Autoimmune/Inflammatory Syndrome Induced by Adjuvants), also known as Shoenfeld’s syndrome. This condition involves autoimmune and inflammatory reactions triggered by substances stimulating the immune system, including implants.

Treatment can be long and complex, often requiring steroids and sometimes methotrexate. Fortunately, most complications are milder and can be managed with hyaluronidase—preferably under ultrasound guidance, which allows for targeted treatment with minimal tissue damage.

In summary, key factors influencing safety include:

• proper patient qualification
• thorough anatomical knowledge
• correct technique
• high-quality products

The Nuances of Anatomy

When studying anatomy, we often underestimate how much individual variation exists. Experience with cadaver training and ultrasound has shown that each patient presents unique anatomical nuances affecting both results and safety.

Ultrasound acts as a “third eye,” allowing us to visualize vascular pathways and precisely control product placement during injections.

Some practitioners believe ultrasound is only useful for treating complications—this is not true. It is equally important for performing procedures safely. Incorrect placement, for example into the SMAS layer containing nerves and vessels, can lead to long-term complications.

I have seen patients with under-eye swelling lasting over a decade due to misplaced hyaluronic acid blocking lymphatic drainage.

There is also growing criticism of hyaluronic acid, with claims that it does not fully degrade. This is not medically accurate—provided high-quality products are used and correctly placed. Problems arise from incorrect technique, excessive volumes, or improper placement.

Similarly, the so-called “overfilled face syndrome” is not the fault of hyaluronic acid itself, but rather poor technique and product misuse.

One major advantage of hyaluronic acid is reversibility—it can be dissolved relatively quickly with hyaluronidase, especially under ultrasound guidance.

The Rise of Biostimulators

Collagen stimulators are currently among the most popular treatments in aesthetic medicine. However, their growing use by less experienced practitioners raises concerns about a future increase in complications.

I personally value them highly, particularly next-generation poly-D,L-lactic acid (PDLLA), but I strongly recommend administering them under ultrasound guidance, as there is no direct antidote.

Recently, complications in the eye area—mainly persistent swelling—have gained attention. In my practice, I use products like Juvelook in the lower eyelid and tear trough area, always informing patients about possible short-term swelling.

However, long-term swelling often results from residual hyaluronic acid from previous treatments. When combined with biostimulators, it can rehydrate and expand, causing complications.

Ultrasound allows proper patient qualification and helps avoid such issues. I regularly conduct training courses in ultrasound-guided PDLLA treatments, including Juvelook and Lenisna.

Indications for PDLLA

PDLLA-based products are highly effective for:

• skin laxity and loss of firmness
• post-pregnancy abdominal skin and stretch marks
• loose skin above the knees or arms
• cellulite and skin quality improvement
• acne scars and uneven skin tone

They are particularly useful for patients requiring lifting without added volume. I often use them to prepare the skin before thread lifting procedures.

In younger patients, I use them more cautiously, focusing on regenerative rather than volumizing effects.

For the eye area, proper qualification and ultrasound guidance are essential.

What Does Ultrasound Provide?

Ultrasound is invaluable at every stage:

• before treatment – for accurate assessment and qualification
• during treatment – for precise and safe product placement
• after treatment – for verification and complication management

Patients often undergo treatments in multiple clinics and may not disclose previous procedures. Ultrasound helps detect unknown fillers, such as silicone oil or permanent fillers, preventing serious complications.

For example, I encountered a patient whose lips contained silicone oil—detected only thanks to ultrasound. Another patient developed severe inflammation after hyaluronidase was used on permanent filler.

Ultrasound also plays a critical role in procedures such as non-surgical rhinoplasty. Due to anatomical variability, vascular structures may not follow standard patterns, increasing the risk of severe complications, including blindness.

This is why I always assess nasal vascularization with ultrasound—and sometimes advise against the procedure altogether.

The Value of Training

Learning ultrasound use allows practitioners to:

• perform safer procedures
• improve precision and outcomes
• reduce product usage
• prevent complications
• treat complications more effectively

Traditional complication management often involves high doses of hyaluronidase, which may damage tissues. Under ultrasound guidance, significantly lower doses are sufficient, preserving aesthetic results.

Ultrasound offers numerous advantages, and I hope its importance will continue to grow among practitioners worldwide.

The face consists of complex, variable structures, yet many training programs rely on overly simplified models.

Male, 38 years old, physically active, with weight fluctuations. Thin skin, pronounced folds, and volume loss in the temples and lower third of the face. One Lenisna treatment – 16 ml administered to the temples, zygomatic area, and jawline. Photos taken immediately before and immediately after the ultrasound-guided procedure. Second treatment scheduled after 3 months.
Photo: Dr Parda Clinic