How to avoid 5 parallel arteries when injecting facial filler
Risk is everything in medical aesthetics, learn to assess it every time you inject dermal filler, because the risks can be significant in certain areas of the face – one of the largest is posed by the location of arteries and other vasculature, get it wrong and you risk causing a vascular occlusion.
In this blog, Dr Tim Pearce will walk you through the five superficial arteries that run parallel to the locations you will be placing your needle or cannula and help you to navigate and understand the danger zones. He will discuss the superior and inferior labial arteries when injecting lips and the dorsal nasal artery for those performing non-surgical rhinoplasty, as well as the facial artery near the nasolabial folds, the supra trochlear artery and frown lines, and the impact of the submental artery on jawline contouring.
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.
Filler injection risk from arteries that run parallel to your needle
Many of the treatments performed by aesthetic clinicians, for aesthetic reasons, place their instruments, needle, or cannula, in parallel proximity with arteries found superficially in the subcutaneous fat within the face – which by default makes injecting riskier, as there is increased risk of accidental cannulation of the vessels and deposition of filler product along the length of it, creating a severe occlusion. Let’s look at five areas where you will encounter this problem.
#1 Avoiding the labial arteries and safely injecting lips with dermal filler
The most common place, and therefore the riskiest area for injection, due to the frequency of procedures performed and the number of reported occlusions must be the lip, a highly vascular area of the face.
The superior and inferior labial arteries both run parallel with the lips. Many classic injection techniques are taught to augment the lips and define the vermillion border and philtrum by placing the needle parallel with the vermillion border meaning that you are constantly and repeatedly putting your needle alongside the arteries and increasing the risk and likelihood of hitting them at some point.
One of the pros (although there are cons) of so-called Russian or tenting techniques, which approach from a 90-degree angle, is that you are not parallel with the vessel, although bruising can be worse with such techniques, there is an argument that you may be less likely to completely fill the artery if you hit it as it will not be fully cannulated with this angle of approach. Anyone injecting lips should be mindful of not injecting too deeply and to always inject small amounts of product with each delivery to reduce the risk of compromise. In most patients, the labial arteries tend to run just below the muscle, so depth of injection is a key mitigator of risk.
By choosing a good quality, soft dermal filler product, suitable for injection into the lips, you will be able to deliver superficial injections – thicker products often have the detriment of forcing you deeper in your injection technique so you can hide them under the tissue.
As you inject, you can easily perform a depth check by lifting the needle upwards to ensure that you see the skin blanch along the surface of the needle, and this disappears as you lower it back down. If you have blanching at rest, with no force across the needle, you are above the papillary dermis and compressing the blood supply out of the dermis. If you inject there you will be able to see the filler, so you should place your needle a little deeper, whilst avoiding going too deep, which would mean that you could lift the whole lip up when performing your depth check.
#2 Avoiding the dorsal nasal artery and safely injecting the nose with dermal filler
The dorsal nasal arteries run along the spine of the nose, either side of the midline, and present a risk when performing non-surgical rhinoplasty with dermal fillers, as delivery of the product runs parallel with the vasculature, whether delivered by sharp needle or blunt cannula, thus, this is regarded as a real danger zone.
Due to the tight space in the nose, Dr Tim believes that cannulas can present more of a risk because as you manipulate the instrument and edge your way up the nose, there is a need for a reasonable amount of force to be expended and if you do push into a blood vessel, the cannula will tend to stay within it as you progress.
Delivery of filler into the nose for the rhinoplasty procedure, such as to contour around a dorsal hump, is often in a bolus, thus the severity of any potential vascular occlusion is more evident, (alongside the risks of causing blindness by filling back into the supra trochlear artery and blocking the retinal artery).
Unlike needles, cannulas are unlikely to be used at 90-degrees to the dorsal nasal arteries to reduce this risk. Dr Tim argues that needles may increase the frequency of arterial compromise in this area due to their more common usage, however, they should reduce the severity of vascular occlusions, causing more easily treated superficial events.
Choosing the right instrument for such procedures can therefore be very difficult, and certainly specialised training in non-surgical rhinoplasty is a must to understand the use of techniques that avoid running parallel with the artery and reduce the risk of causing an occlusion. These include a 90-degree approach, delivering product on the periosteum (below the artery) with the needle bevel pointing downwards, approaching treatment in the midline, finger compression of the supra trochlear artery during injection, aspirating regularly, and the use of smaller volume deposits of filler product.
#3 Avoiding the facial artery and safely injecting nasolabial folds with dermal filler
The facial artery, which is the main blood supply for the face, runs laterally to the nasolabial fold and cosmetic injections in this area often run parallel, whether with needle or cannula. Dr Tim notes that individuals of Chinese descent differ in their anatomy and the facial artery often sits in the nasolabial fold which increases the risk of vascular occlusion in such patients.
Depth of injection is the most important factor when injecting the nasolabial folds, many aesthetic clinicians advocate a deep, periosteum level injection in this area, because the artery tends to run through the fatty layer above. Alternatively, you can take a superficial approach, injecting into the dermis, above the fat pad – remember your depth checks – to address a crease in the tissue, rather than significant volume loss. Another tip is to palpate the area as often the facial artery can be readily located.
#4 Avoiding the supra trochlear artery and safely injecting frown lines with dermal filler
The supra trochlear artery presents a more complex risk to aesthetic injectors, starting deeper in the tissue (entering on the periosteum), but progressing more superficially as it extends higher up the face. If you are attempting to treat a frown line with dermal filler, a common patient request, then you will be parallel with this artery, hence, it is often regarded as a no-go area.
A multi-step approach is needed to safely consider injecting in this area, and it is certainly an advanced technique that should not be attempted by novice injectors. Depth is the key factor, employing the most superficial of injections with aspiration, the bevel of the needle pointing upwards, compressing the artery during delivery, and the use of a small volume of product. Ideally, you should also check the capillary refill time after completion to be satisfied of a successful outcome.
#5 Avoiding the submental artery and safely injecting the jawline with dermal filler
If you place a needle parallel to the jawline when contouring, you will encounter the submental artery running along the inferior side of the mandible. This artery is highly palpable so should be easy to locate in your patients, but it presents a risk when injecting in this area. Causing a vascular occlusion along this artery would present as a compromise in the blood flow to the chin.
To safely inject, often with a cannula, aesthetic clinicians must ensure the mobility of their instrument, restricted movement, or a sense of being tethered implies cannulation of a vessel rather than placement within the fatty layer. Aspiration is highly recommended, as with all these danger zones, and even when using a cannula. Moving the cannula as you inject to ensure small deposition of product along the length of the jawline reduces the risk of severe vascular occlusion or compromise through compression. Avoiding a parallel injection technique is difficult in this area due to the aesthetic result being targeted.
Get your hands on an anatomy poster and download a free facial vessel map
Why not download a free and helpful guide on the 13 extra risky injection areas which includes a facial vessel map or you can buy a limited edition facial anatomy poster for your aesthetic clinic as a helpful reminder of the vasculature of the face.
Aesthetics Mastery Show
AVOID! The 5 Dangerous Arteries That Run Parallel To Your Needle/Cannula
This blog accompanies a popular Aesthetics Mastery Show, where Dr Tim Pearce looked at the riskiest areas of the face to inject, explaining the 5 arteries that run parallel to where your needle or cannula goes, thus increasing the likelihood and severity of vascular occlusion.
Watch the full Aesthetic Mastery Show episode here:
Are you still anxious about delivering cosmetic injectables safely?
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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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