Buccal Cavity Tear Trough Injection

Comparing entry points for safety and outcomes

A viral video showed a board-certified plastic surgeon filling tear troughs through the buccal cavity, an entry route that prompted questions from injectors worldwide. The patient looked relaxed and comfortable as the experienced surgeon deposited filler through this unconventional approach, and the surgeon’s credibility makes this technique worth analyzing beyond simply dismissing it as different.

New injectors frequently encounter contradictory advice from authority figures in aesthetics. It’s important never to simply copy anyone, regardless of their credentials. Understand their reasoning and evaluate whether it makes sense given your other training first. This builds upon existing knowledge instead of creating insecurity from switching between trends.

The injector refers to a needle at one point in the video, but based on how it pushes tissue, this seems to be a cannula. The cannula was inserted under the top lip into a hole in the buccal cavity, cleaned with Betadine solution before the procedure.

Buccal approach anatomy

The cannula is pointed straight up toward the orbit, passing underneath all facial muscles, past the infraorbital artery origin and nerves, through the deep medial cheek fat, parallel with the possible position of the angular artery. The angular artery sometimes crosses over from lateral to medial more superiorly in a significant minority of cases. The cannula also travels alongside the angular vein, probably passing quite closely, likely inferiorly, just before entering the sub-orbicularis oculi fat (SOOF).

After passing through the orbital retaining ligament, the product reaches the suborbicularis oculi fat. All injectors aim to place tear trough filler in this location. The result looked good with this unconventional technique, the patient looked happy, and the injector claims decreased pain with minimized bruising.

This procedure isn’t commonly done this way. No evidence proves anything wrong with this approach because virtually no solid evidence exists for anything we do in aesthetics. Collectively, we can only think through procedures, risks, and benefits from first principles.

Treatment objectives for tear trough injection

Volume replacement in the tear trough requires minimizing trauma to nerves, arteries, and veins while avoiding vascular occlusions and minimizing infection risk. The procedure must be as comfortable as possible for patients.

Deeper injection carries lower risk for aesthetic problems in the tear trough, such as edema or puffiness that may occur over time.

Analyzing this procedure doesn’t involve judging the specific injector without knowing enough about the patient or their skillset. The analysis anticipates how this procedure plays out in average injector hands, where it becomes easier to foresee potential injury when attempting to replicate the process.

Technique choice revolves around minimizing the impact of drifting from perfect execution. Everyone drifts from time to time, but this happens much more often in the first few years of practice. What would the impact of going too deep, too medial, too lateral, or too superior be with a particular angle of entry?

Potential advantages of buccal entry

The entry point sits so deep with respect to the anterior face that bruising risk may genuinely be lower, especially with a cannula. Vessels including the facial artery close to the entry point likely sit above the instrument. Any trauma at the entry point also becomes more invisible to the patient because it’s deep relative to visible tissue.

Entry depth makes finding the superficial plane unlikely, which aligns with treatment goals since deep injections for tear troughs produce better outcomes. The cannula travels behind all major facial muscles.

Infection risk considerations

The primary concern if injectors collectively switched to this technique centers on infection. The area was cleaned beforehand, but the patient’s normal flora will instantly bathe that entry point within the first minutes after the procedure.

A small hole in tissue probably doesn’t pose a major risk for most patients since this entry is routine in dentistry for nerve blocks. The additional risk involves the cannula dragging bacteria all the way into the area where filler is placed. The combination of filler and bacteria creates serious complications.

Thorough cleaning of the area can likely mitigate this well, but it intuitively feels riskier than the percutaneous route.

Anatomical structures in the cannula path

The cannula path crosses important structures. The infraorbital nerve, artery, and vein all become vulnerable to trauma, even from a cannula. Pushing the cannula fractionally deeper than intended straight into the foramen would be uncomfortable at minimum. An extremely experienced person may be less likely to do this, but it’s an inherent risk of that angle of entry.

Just before entering the SOOF, you’re likely to encounter the levator labii superioris at its origin since we’re so deep at the entry point. Occasionally finding a way through this could pose an obstacle or cause discomfort or pain.

At that same point, the angular artery runs parallel to the instrument and probably medial, while the facial vein would likely sit very close, occasionally directly in the cannula’s path.

None of these guarantee complications or even problematic procedures in every case, but these structures are worth considering when deciding the best path to enter the SOOF.

Risk of posterior orbital penetration

The risk of the cannula going too far also matters. With this angle of entry, we’re pointing directly at the eye. In many patients, herniation of retrobulbar fats and the ocular membrane increases the chance of filler making its way behind the orbital septum.

Dr. Masser discovered this complication using MRI, filler causing persistent swelling in the orbit that becomes resistant to superficial hyalase treatment.

Lateral cheek approach comparison

Analyzing any technique requires an alternative for comparison. The more common technique uses entry into the lateral cheek superior to the zygomatic ligament and inferior to orbicularis oculi ligament. The cannula then passes through cheek fat underneath the muscle.

This technique avoids most arteries, nerves, veins, and muscles. The entry point is more easily cleaned and kept clean after the procedure.

Going too superior can still allow passage into the orbit, but the angle makes this less likely. Going too deep most likely results in the cannula hitting the nose rather than the globe.

One potential downside involves arteries and veins that, in a minority of cases, run parallel with the cannula, making occlusion potentially more likely. Occlusions in this area are very rare.

The extremely thin skin around the eye makes it easy to locate the cannula and be certain you’re not injecting into a vessel. This applies to whatever angle of entry you’re using.

Why lateral cheek entry is favored

The conventional approach offers a simpler and lower risk technique with respect to infection and the number of structures in the cannula’s path, based on anatomical understanding. The more common lateral cheek entry point may miss something in this analysis, but the infection risk and anatomical pathway considerations favor the established technique for most injectors.

FREE Complications Webinar

Want to overcome your fear of complications and confidently master anatomy?

Join us for one of Dr Tim's FREE upcoming webinars. .

Check dates here and save your spot

Complications Webinar