Dermal fillers: the best and worst nasolabial fold injection points

A video of dermal filler injections to treat nasolabial folds was recently shared with Dr Tim Pearce by a fellow aesthetic clinician and it made him cringe. He was immediately taken aback by the injection point used and the angle of the needle as a credible approach to injecting the nasolabial fold area.

In this blog, Dr Tim Pearce shares why he would never inject this way to help you build up your own mental model of how the anatomy works, how small things like injection depth, needle position, and angle matter and can completely change the likelihood of causing a vascular occlusion, as well as impacting on the resultant aesthetic outcome.

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Never inject the nasolabial fold like this!

Reviewing the video, Dr Tim notes that it is an unusual practice because the entry point for the injection is above the nasolabial fold. The injection is just lateral to the ala crease and is projecting the middle part of the cheek outwards, slightly above the nasolabial fold.

Bearing in mind the lack of context when viewing a video from social media, there are multiple things that make little sense. Firstly, why would you want projection in this area? Usually, as aesthetic clinicians, we are trying to increase the volume in the nasolabial fold and decrease the relative size of the cheek in this area, whereas in this case, they are projecting that part of the cheek outwards. Therefore, the aesthetic result is something that Dr Tim would question, but that is a subjective consideration compared to the more important issue of safety in relation to the anatomy. He reminds practitioners that our main purpose when injecting is to try to achieve the desired result without causing an injury.

In this specific video, there was no evidence of aspiration, although, we know that medical professionals do argue over the sensitivity of aspiration, but a riskier bolus technique is also being employed. Consequently, if you do a high-volume injection with minimal safety checks, such as without aspiration – we do not know from the video whether ultrasound scanning was done beforehand which may alter parameters – then it is certainly possible to conclude that it is probably riskier than a high-volume injection with aspiration. Aspirating does not mean that you will never get a vascular occlusion, but it does detect approximately 50% of the occasions when your needle is placed intravascularly.

The anatomy of the nasolabial fold

Knowledge of the anatomy in the nasolabial fold region will help you to understand why this is not a recommended injection approach. This area of the face is highly vascularised and there are quite a few blood vessels within approximately 1.5cm of the injection point highlighted in the video.

The most important vessel is probably not the one that most practitioners will think of first, because most would think about the facial artery. The facial artery in this area tends to run in the fat, and therefore, it is usually not on the periosteum. This means that if you are deep with your injections, you are likely to be safe. Dr Tim surmises that this is probably the main factor that the injector in the video is using to gauge their safety.

But, the real problem, as viewed by Dr Tim is that because the entry point is superior, it is outside of the nasolabial fold, and this brings the needles closer to the infraorbital artery. The infraorbital artery passes its vessels from lateral to medial. If you attend a cadaveric training course, these are the vessels that you find usually on the bone because they have just emerged from the infraorbital foramen, on the bone, and you will often still find vessels at this depth. This presents the main reason for critiquing this specific injection point; there is very clearly a risk of intercepting some of the infraorbital vessels.

When treating the nasolabial fold, one of the complications that has been noted is a severe vascular occlusion affecting the infraorbital artery. This goes on to affect the blood flow in the maxillary artery, which can further impact blood supply to the soft pallet and the nasopharynx. This could be a very nasty, internal vascular occlusion when a high volume of dermal filler is injected into the infraorbital artery, and Dr Tim believes this would be the risk when undertaking the style of injection demonstrated in the video.

This approach – where the needle is touching the periosteum and in theory underneath the facial artery but very close to the branches of the infraorbital artery – is riskier than the normal – much lower down – injection point for treating nasolabial folds. Similarly, there is a chance of impacting the lateral nasal artery from this entry point, hence, overall, there is a combined risk of intravascular injection or ‘skewering’ leading to bruising of the facial artery, a branch of the lateral nasal artery, and branches of the infraorbital artery, which is not a consideration with more a commonplace entry point lower down.

Read more on treating nasolabial folds with additional insight from Dr Tim:

• Treating nasolabial folds – botulinum toxin versus dermal filler
• Should you treat cheeks or nasolabial folds with dermal filler?

Dr Tim is always keen to hear about the experiences of his followers. So, if you have any questions, case studies, or discussion points for him, you can find Dr Tim Pearce on Instagram

Aesthetics Mastery Show

Never Inject Like This! The best & worst nasolabial fold injection points.

Dr Tim says:

“I was recently sent a video from a fellow clinician and I was immediately taken aback by the injection point used and angle of the needle to inject the nasolabial fold area. There’s a few reasons why I don’t recommend injecting this way and it mostly includes the placement of the arteries in this area and the potential for trauma. In this episode I discuss why I don’t recommend injecting this way, the anatomy involved, plus the safest and best ways to inject this area in my experience.”

Watch the full Aesthetics Mastery Show here.

The video has received over 7k views and a variety of constructive feedback from subscribers and viewers on the YouTube channel, including the following comments:

@juliejory said:

“I love that we think so much alike. Thank you for your constant education for the injector masses”

@Tannertheinjector added:

“I saw Julies case when I was 14 years old on Realself. She had lido with epi used as well, and had Radiesse which is irreversible. I never thought I would suffer a VO, even on myself but in July this year 2023 I suffered a VO and it was the scariest time of my life. This was a great video. This is what I teach my injector who is shadowing me. Great video and yes knowledge of anatomy, and cadaver sessions really help an injector improve.”

Read more comments and join in the debate on our YouTube channel.

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Dermal Filler eLearning Courses

If you want to increase your knowledge about safe and effective dermal filler injectable treatments, Dr Tim Pearce offers a series of fabulous courses. The foundation level is a popular starting point, with many delegates continuing to complications courses focused around safety, including how to minimise the risk and how to handle things if the worst occurs:

• Dermal Fillers Foundation Course
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In addition, browse our FREE downloadable resources.

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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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