Pre-Injection Doppler Mapping Versus Landmark Guidance for Lower Facial Hyaluronic Acid Injection in a Prospective Safety Study

Summary

This prospective study suggests that pre-injection Doppler mapping can improve vascular risk assessment and early outcomes in lower facial hyaluronic acid injection. Compared with landmark guidance alone, Doppler mapping identified individualized vascular risk signals, supported pre-injection plan modification, and was associated with lower post-injection ecchymosis and improved short-term aesthetic scores.

Abstract

This study evaluated whether pre-injection Doppler mapping improves vascular safety and early aesthetic outcomes in lower facial hyaluronic acid injection compared with landmark guidance alone. In this prospective parallel-controlled study, 120 participants were randomly assigned to a Doppler mapping group (n = 60) or a landmark-guided group (n = 60). Vascular risk signal detection, post-injection ecchymosis, procedural features, and early aesthetic outcomes were compared between groups. Detectable vascular signals were identified in 63.3% of Doppler-group participants, and injection-plan modification was performed in 53.3%. Ecchymosis incidence on day 3 was significantly lower in the Doppler mapping group than in the landmark-guided group (23.3% vs. 48.3%; P = 0.004). Needle passes, intra-procedural adjustments, and overall early adverse events were also reduced. Aesthetic improvement scores and patient satisfaction were higher in the Doppler mapping group. In multivariable analysis, pre-injection Doppler mapping was independently associated with a lower risk of ecchymosis (OR = 0.38; P = 0.014). These findings suggest that pre-injection Doppler mapping may reduce vascular risk and early local trauma while improving short-term aesthetic outcomes after lower facial hyaluronic acid injection.

Introduction

With the continuous updates of modern facial aesthetic concepts, the treatment concepts have also transitioned from single local wrinkle injection to overall facial shaping across the entire face^1,2. Consequently, comprehensive rejuvenation of the lower face has become an essential component of contemporary aesthetic practice. As the key area that determines the facial-neck boundary and vertical facial proportions, the aging process of the lower face is a multi-faceted pathophysiological change, including deep bone tissue atrophy, loss of soft tissue volume, and gravity-induced descent of fat pads

Protocol

The study protocol was reviewed and approved by the institutional ethics committee of Chengdu YiXing Plastic Surgery Hospital (Approval Number: ETUAA80928). All participants provided written informed consent before enrollment and before standardized facial photography. Written consent was also obtained for the publication of identifiable or potentially identifiable facial photographs included in the manuscript. The study was conducted in accordance with the Declaration of Helsinki and local clinical research requirements.

Study design

This study was a single-center, prospective, parallel-control cl....

Results

Baseline characteristics of the study population

A total of 120 subjects were recruited from patients receiving lower facial hyaluronic acid injection; 60 were assigned to the Doppler mapping group and 60 to the landmark-guided group. All subjects completed baseline assessment and were included in the analysis. The two groups were demographically comparable and had similar treatment-related baseline characteristics, as shown in Table 1.

Discussion

This prospective controlled study compared pre-injection Doppler mapping with landmark guidance alone for lower facial hyaluronic acid injection^12,13,14. The main finding was that Doppler mapping was associated with more frequent pre-injection identification of vascular risk signals, more planned route modifications before injection, fewer trauma-related procedural events, lower early ecchymosis, and better short-term aesthetic .......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Blunt-tip cannulas	TSK Laboratory International	https://shopeu.tsklab.com/product/steriglide-cannula-30g-x-25mm/	Sterile blunt-tip cannulas, 25–30 G. Used for broader subcutaneous filler distribution and for reducing local tissue trauma when avoidance of superficial vascular pathways was required.
Color Doppler imaging mode	Mindray Bio-Medical Electronics Co.	/	Superficial facial vascular mapping preset, used to identify superficial and deep blood-flow signals and to evaluate their spatial relationship to the planned hyaluronic acid injection plane.
Cross-linked hyaluronic acid filler	Allergan	/	Juvéderm Voluma XC, used for lower facial contour correction and soft-tissue augmentation in the mandibular border, mandibular angle, pre-jowl area, labiomental fold/marionette line region, chin, and superficial lower-lip refinement area.
Digital facial photography system	Chengdu YiXing Plastic Surgery Hospital	/	Standardized lighting, positioning, and facial-angle protocol; used to obtain standardized pre-treatment and post-treatment facial photographs for blinded assessment of ecchymosis and early aesthetic outcomes.
High-frequency linear-array ultrasound probe	Mindray Bio-Medical Electronics Co.	/	L20-5s linear-array probe, used to visualize skin, subcutaneous fat, muscle layers, deeper supporting structures, intended filler plane, and adjacent vascular signals before injection.
High-frequency ultrasound system	Mindray Bio-Medical Electronics Co.	/	Resona 7 Diagnostic Ultrasound System, used for pre-injection gray-scale ultrasonography and Doppler vascular mapping of lower facial soft-tissue layers and vascular risk signals.
IBM SPSS Statistics	IBM Corp.	Version 26.0	Used for statistical analysis, including normality testing, independent-samples t tests, Mann-Whitney U tests, chi-square tests, Fisher exact tests, and binary logistic regression models.
Povidone-iodine skin disinfectant	Shandong Lircon Medical Technology Co., Ltd.	/	Standard clinical skin disinfectant, used for routine treatment-area disinfection before lower facial hyaluronic acid injection.
Sharp injection needles	TSK Laboratory International	/	Sterile sharp needles, 30–32 G, used for precise focal filler placement when periosteal, deep-plane, or region-specific structural support was clinically appropriate.
Sterile marking pen	Viscot Medical, LLC	/	Used to mark lower facial treatment areas, surface landmarks, planned entry points, and Doppler-adjusted injection routes.
Sterile ultrasound gel	Parker Laboratories, Inc.	https://www.parkerlabs.com/product/sterile-aquasonic-ultrasound-transmission-gel/	Used to improve acoustic coupling during pre-injection gray-scale ultrasound and color Doppler assessment.