I Thought Using Ultrasound To Guide Injections Was Just Another Safety Measure. Then I Interviewed One Of The World’s Leading Experts.

 Last week, I had one of those brain-upending conversations that made me reconsider so much of what I thought I knew about injecting in the face. Before this chat, if you’d asked me about ultrasound imaging in aesthetics, I’d have shrugged. I’ve seen it done. The practitioner scans the face in front of them, then does their injections with the ultrasound device on the face, so they can see exactly where their needle tip is. Useful for avoiding blood vessels, and very helpful for precise dissolving of problematic filler, but something every injector needed? Not really.

But then I spent an hour talking to Dutch cosmetic physician Dr Leonie Schelke, who is one of the world’s leading experts in ultrasound-guided aesthetic injections. She runs a busy clinic at the Department of Dermatology at Erasmus University in Rotterdam, both injecting filler and dissolving it under ultrasound, and researches how filler behaves beneath the skin, and several things she said fairly stopped me in my tracks.

Why ultrasound has traditional seemed like an optional xtra

Ultrasound devices have been used in aesthetic medicine for long enough that they’re no longer a novelty, yet they’ve had a limited impact. Most injectors see this imaging as a curiosity, and don’t use it because, well, they know their anatomy! Sure, it’s good for complications, but they’ve been injecting for years and getting great results, so why bother? Dr Schelke manages not to sigh when I bring this up. “15 years ago, we were told we were fearmongering,” she says. “Now there is so much research no one can say it’s ridiculous, but the general view is that an experienced doctor does not need ultrasound. The difficulty with this is that everywhere you look in medicine, in orthopaedic surgery, or neurology, if you inject under ultrasound, you have much greater accuracy than if you don’t. 88% accuracy with ultrasound versus 50% without, according to a systematic review of ultrasound guided injections for botulinum toxin. Nowadays, no anaesthetist would inject a long line without ultrasound. But they used to.”

So did you actually get the treatment that you paid for?

Only 50% accuracy? “That’s terrifying,” I say. “Exactly,” says Dr Schelke drily. “That was my purpose, to terrify you.” She sees the results, what she calls “unintentional filler placement” every day – both in her three-days-a-week complications clinic, which is booked out six months in advance, and on her normal, non-complications days, where she still scans every face, just to see what’s going on in there. “People have paid for the treatment,” she says, “but it’s not giving the results they were expecting.” Has she tried to do an study comparing the accuracy of filler injections with and without ultrasound? “Yes, but non-ultrasound-users do not want to participate as they feel vulnerable ‘to be checked’,” she says.

Why is so much filler ending up in the wrong place?

It’s not that aesthetic injectors don’t know their anatomy, she explains; it’s because anatomy varies from person to person. Fat layers are thicker in some people than others, ditto muscle. Arteries wander away from where textbook diagrams place them. Practitioners might think, for example, that their needle was right down on the bone, when in reality it may be ending up in a different layer of tissue, namely the SMAS, (the muscular layer of connective tissue that sits under the skin and the superficial fat, and right above the deeper facial fat and the bones). Ultrasound lets you see where you are in real time.

What happens when filler or biostimulators end up in the SMAS?

Why does this matter? You really don’t want filler in the SMAS, not least because it’s full of blood vessels and nerves. Filler is meant to be placed deep, against the bone, or in the layer just beneath the skin to do the job it’s designed for. Put it in the SMAS and everything goes a bit stiff and lumpy. We’ve all heard facial plastic surgeons complaining that they find filler in the SMAS, which makes surgery more tricky. “Yes,” says Dr Schelke, “because if filler is injected in the SMAS, we see that it stays for many years. If it’s in the right place, it will be reabsorbed over time. Also, remember that HA fillers can be dissolved. Biostimulators cannot.” Eek.

Yet Dr Schelke is still a fan of filler.

I’m reassured to hear Dr Schelke is not anti-filler. Not at all. It’s a great product that she uses in her clinic every day. “My biggest fear is that people won’t want to have hyaluronic acid any more.” However, she would never inject a face without scanning it first, because that determines her treatment plan. If she finds existing filler, there may not be room to add more, because if more was added, it would move. “Is that migration?” I ask. “Not migration,” says Dr Schelke, “but yes it would move because the tissue architecture causes a very predictable filler spread in the fatty layer where the filler is injected, whereas migration is unintended displacement of filler.”

This is news to me and sends my mind reeling all over again, wondering if there needs to be a whole new update to the way anatomy is taught to injectors. I appreciate that this is all getting a bit complex, but stick with me: Dr Schelke’s latest research into filler movement within the skin suggests that filler follows tiny fibrous pathways through the face, and that the direction it will move, if too much is injected, is predictable. Anyone who wants to read the research can find it here, Analysis of Filler Spread: Facial Retinacula play a Prominent Role, Dermatological Surgery, April 2026).

Do practitioners need to rethink the way they’re injecting?

One thing that has always puzzled me about aesthetic ultrasound is this: if gives your injector X-ray vision – why are they not all rushing to use it? The device isn’t particularly expensive either. I’ve heard that learning to use it is a bit of a faff though (and when I’ve asked practitioners who have bought an ultrasound device but haven’t really used it, they mutter apologetically that they need to take a bit of time to get used to it.)

So what’s the big myth about ultrasound?

What’s the biggest myth around ultrasound in aesthetics today? I ask Dr Schelke. “That we don’t need it,” she replies without hesitation. “No practitioner who starts using it stops using it.”

Will ultrasound become routine? Standard? Compulsory even? Who knows. But in another 15 years’ time, we may wonder how we were ever happy to be injected blind. Like at the start, a week ago, if you’d asked whether I cared if my injector used ultrasound, I’d probably have shrugged. But now, I’d ask the question. Not because I think injectors who don’t use ultrasound are doing poor work – far from it. It’s more because once you’ve heard someone explain what can be seen under the skin, it’s harder to feel comfortable with the idea of injecting without that added insight.

Dr Schelke and team have begun compiling a global database of practitioners who inject under ultrasound: www.scanyourfiller.com. Take a look for a practitioner near you, and if you’re a practitioner who uses ultrasound, you can add yourself to the map on that website with a few clicks.