1. MRI OF FACIAL COSMETIC INJECTABLE FILLERS: AN ANALYTIC APPROACH for IDENTIFICATION OF INJECTED SUBSTANCE, COMPLICATIONS AND SYMMETRY OF INJECTED SITES
Sigal Tal1, Hillel Maresky1,  Theodore Bryan1, Assaf Persitz2 & Lior Heller2
Departments of Imaging1 & Plastic Surgery2
Assaf Harofe Medical Center
Sackler School of Medicine, Tel Aviv University

2. disclosures
Authors have no financial or other conflicts of interest to disclose

3. background Cosmetic Injectables gaining popularity in Western World
Substances include: Silicone, Saline, Polymers (i.e.: Bioalcamide), Collagen, Hyaluronic Acid
“Industry of Injectors” widely unregulated

4. Non invasive?
Despite being considered non-invasive, the injection of facial fillers can result in several complications.
Complications:
Infection
Overfilling, Migration / Asymmetry
Foreign-body Granuloma
Reaction (early/late) & Scarring
Adverse reactions can be associated with the procedure itself, the physician technique, and the agent injected.

5. Mri of injectables Role of Imaging added value:
Identification of Substance
Illustration of Complications  help guide clinician & outcome
Evaluation of Symmetry

6. purpose
To investigate the viability of MRI to identify injected substances in the facial region, its symmetry in the face and complications.

7. methods
Patients with suspected injected filler complications were identified by the plastic surgery service.
Patients were scanned with MRI using T1 Dixon non-contrast, T2 Dixon, and T1 Dixon after gadolinium injection sequences.
Two independent and blinded radiologists evaluated the images and reported (1) likely injected substance, (2) symmetry, and (3) complications.
Radiologic results were compared with clinical data provided by the plastic surgeon.

8. Which substance used?
Substance identity may be unknown or misrepresented, especially if injected by non- professional.
Substances behave differently on MRI according to their water, protein & fat content.
Deciphering exactly which substance was injected is important to understand, especially when complications arise.

9. Commonly injected substances
Calcium hydroxylapatite
Collagen
Liquid Silicone
Polytetrafluoroethylene
Hyaluronic Acid
Poly-L-lactic Acid
Polyacrylamide Gel (i.e.: bio-alcamide)

10. How substances “behave”
polyacrylamide gel
hyaluronic acid
collagen
silicone
Agent T1 T2
T1fs
T2fs
Polyacrymalide
hypo-iso
hyper
iso-hyper
Hyaluronic Acid
hypo
Collagen
Silicone

11. results Thirteen subjects underwent MRI (12 female, 1 male).
Seven patients contained polyacrylamide gel injection, three hyaluronic acid, two collagen and one silicone
(One patient had concurrent hyaluronic acid and calcium hydroxyapetite.

12. Inter-rater agreement
Ten patients (83%) demonstrated objective injectable complications: four demonstrates abscess, four granulomata, and two allergic reactions to injected substance.
Inter-rater concordance of substances was 0.8 using Fleiss` Kappa (substantial agreement)
Asymmetry was identified in six patients (50%) and kappa agreement between readers was 1.0 (perfect).

13. POLYACRYMALIDE INJECTION
לשים תמונה של T1 FS שמראה היפר אינטנסיות להוסיף תמונות יותר מייצגות

14. POLYACRYMALIDE INJECTION

15. POLYACRYMALIDE INJECTION

16. HYALURONIC ACID INJECTION
להוסיף תמונות יותר מייצגות

17. HYALURONIC ACID INJECTION

18. Collagen injection

19. SILICONE INJECTION

20. Abscess formation
חסר T1 אחרי הזרקה של האבסס

21. Abscess formation
חסר T1 אחרי הזרקה של האבסס

22. Acute allergic reaction

23. Delayed reacton
לשים תמונה של T1 FS אחרי הזרקה שרואים האדרה

24. Delayed reacton
לשים תמונה של T1 FS אחרי הזרקה שרואים האדרה

25. conclusions
MRI of the face is a reliable tool to identity injected substance
MRI is excellent for tracking and illustrating complications of injected fillers
MRI may be a potential future post-injection mechanism to evaluate over-filling/migration with respect to evaluation of symmetry
לפצל לנקודות

26. THANK YOU!