Do not inject filler deeply in these 6 danger areas of the face
Every part of the face has an aesthetic indication that leads aesthetic clinicians towards injecting dermal fillers for cosmetic enhancement, but first and foremost, we must respect the underlying anatomy when considering the aesthetic improvement achievable so as not to put the patient at unnecessary risk of complication.
Learning how to safely inject multiple facial areas will allow you to determine the aesthetic results you can create, and just where you can place your needle.
In this blog, Dr Tim Pearce explores the 6 most dangerous areas of the face when it comes to cosmetic injections and why you must NOT inject deeply in these areas due to the risk of occluding blood vessels that could result in serious consequences for both you and your patient. He will discuss important anatomical structures including the supraorbital notch and the mandibular groove and why these areas pose so many risks for aesthetic clinicians injecting dermal fillers into the face.
Dr Tim will be discussing more medical aesthetic training tips as part of his upcoming webinar series, so if you’re looking to increase your CPD-certified learning and want to learn more skills to make you a better clinician, then step one is to register for the free webinars by Dr Tim.
Avoid complications by understanding the danger areas and arteries to steer clear of when injecting dermal fillers
Supratrochlear and Supraorbital Arteries (Forehead)
Aesthetic clinicians need to be careful of two important arteries within the forehead – the supratrochlear artery and the supraorbital artery. These supply blood to the forehead and originate from the orbital blood supply, which makes them particularly dangerous for aesthetic injectors because they are connected to the same blood supply as the retina.
You can feel for these arteries by locating the bony notch where they emerge from the skull, the supratrochlear notch. This is medial to the nose and the supraorbital foramen is more lateral. As well as feeling the bony shape, you may also feel a pulse, especially if the patient is nervous and has an elevated heart rate.
As these are easy to locate, they are also easy to avoid, plus we know that if you inject deeply in these areas, this is where the danger lies. A periosteal injection around the orbital rim is therefore an absolute no-no for aesthetic practitioners.
To inject this area safely, you must understand the layers of the anatomy and the appropriate techniques you can use to mitigate the risk of vascular occlusion and causing blindness. Many may argue that it is an area to avoid completely, but Dr Tim believes you can balance the risks if there is a credible benefit to the patient from the resulting procedure, such as a very deep frown line that causes upset in social interactions. He recommends injecting away from the orbit, with the needle pointing in the opposite direction; compressing a vessel during injection to avoid any ingress by the filler product; aspirating (even when using a cannula); choosing an appropriate product based on viscosity; and using small volumes. You can consider using a blunt cannula in lieu of a sharp needle depending on the indication. Similarly, it is crucial to understand the depth of your injection; you must inject superficially in this area, and not on the periosteum where the arteries, and the danger lies.
Infraorbital Foramen (Nasolabial)
The infraorbital foramen is located just medial to the mid-papillary line, thus when drawing a line down the face from the middle of the pupil of the eye, we find an area that poses a significant risk when injecting dermal fillers, due to the location of significant vasculature including the facial artery.
Finding the infraorbital foramen is quite easy because it is a palpable area which often feels tender when pressed because the facial nerve also emanates from this location. Put bluntly, we simply do not want to be putting a needle deeply in this location due to the risk of occluding an artery; as a branch of the maxillary artery, if you were to occlude a vessel in this area you would block blood supply to much of the mid-face, the hard and soft palate, and the nasopharynx. Injecting above the infraorbital foramen, i.e., superficially, in the fatty tissue is considered safer.
To safely inject in this area, consider marking out your patient so you can establish your known anatomy and then you can avoid the area of the infraorbital foramen. There are very few indications why you would even consider adding volume, so for most aesthetic clinicians, it is an easy area to avoid. If you do intend to treat, you may consider approaching the area using a cannula rather than a needle for added safety. The need to deliver injections into the nasolabial folds in modern medical aesthetic treatments has all but disappeared with better knowledge learnt in recent decades, thus many clinicians now volumise the face in areas above, laterally, or inferiorly to the nasolabial area. This has the effect of supporting the structures to reduce the appearance of folds, without the need for direct treatment.
Mental Foramen (Chin)
The mental foramen is located at the side of the chin and is the exit point for the mental artery, it sits in a parallel line with the infraorbital artery and is approximately a centimetre lateral to the marionette lines.
Again, the advice is avoidance of injecting deeply in this area if performing chin volumising treatments because blocking the mental artery with dermal filler can result in superficial occlusion of the blood supply to the skin on the chin and to the mentalis muscle. Although, with a significant blockage from a large volume of filler product, it could impact much further back into the lower face because this vessel exits from the mental foramen as a branch of the inferior alveolar artery and could therefore affect the blood supply to the teeth and the floor of the mouth if occluded further back.
To safely inject the area, consider palpating to locate and avoid the mental foramen, deliver small volumes of product, gauge patient reaction, switch to a cannula, and do not inject deeply onto the periosteum.
Facial Artery (Jawline)
The entry into the face of the facial artery is via the mandibular groove on the edge of the jawline, easily located when running a finger along the jawbone.
All aesthetic clinicians should avoid placing a needle directly into this notch, for fear of occluding the blood supply to one side of the face.
Jawline contouring treatments often involve periosteal injections, but these should be placed a few centimetres laterally to this area to avoid risk.
Further contouring down the line of the mandible can be achieved with the use of a wide-bore cannula within the soft tissue layer, and not on bone.
Deep Temporal Arteries (Temple)
The pair of deep temporal arteries are located within the lower temple, to the side of the eyes, and run on the periosteum, behind the zygoma, supplying blood to the temporalis muscle.
The deep temporal arteries are therefore different to the superficial temporal artery, but they are all in an area where clinicians are likely to be injecting to revolumise the temple area and are considering placing periosteal, bolus injections. The deep temporal arteries connect to the maxillary artery; thus, an occlusion could impact on the mid-face. Common delivery options include the Swift Point, named after Dr Arthur Swift, who pioneered the technique which uses a large bolus, placed high and lateral in the temple where the placement of the filler is superior and more medial to the temporal vessels.
For more up to date guidance on injecting the temple, consider reading Dr Tim’s recent interview with Dr Patricia Oyole where she discusses her recent findings from anatomical dissections of the temporal area, alongside what Dr Tim discovered when he used an ultrasound device to locate temporal vasculature on his wife Miranda. We are always learning!
Aesthetics Mastery Show
Injection technique highlights from 2021
This blog follows our recent Aesthetics Mastery Show, which summarised some of 2021s most viewed dermal filler injection technique clips.
Are you still anxious about delivering cosmetic injectables safely?
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Further complications resources
If you want to increase your confidence by learning how to handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:
Both give CPD and certificates on completion.
In addition, browse our FREE downloadable resources on complications.
Dr Tim Pearce eLearning
Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.
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