Dermal Filler: Top 10 Danger Zones

Top 10 Danger Zones for Dermal Fillers

How to avoid intravascular occlusion or constricting pressure

In the U.S. over 2.6 million dermal filler injection treatments in 2017.  It is imperative that we as medical providers to keep patients safe. Bruising, tenderness and swelling after having dermal fillers is expected. Direct Vessel occlusion or non-direct vessel constriction are very serious complications. Vessel occlusion or construction can lead to damaging tissue, necrosis and in rare cases visual impairment, blindness or distal embolism.

 Danger Zones 1 and 2: Supraorbital and Supratrochlear Arteries in Glabella

The number one area for neurotoxins like Botox, Dysport and Xeomin. For dermal fillers, the glabella is the most dangerous. The entire area is a no-go zone

In the upper corner and at mid pupillary along the supra orbital rim there are two sets of arteries:  the supratrochlear and the supraorbital arteries.

Both sets of arteries are small and have little to no collateral circulation. They initially run deep and then becomes more superficial about an inch above their foreman.

These arteries supply blood to muscles and skin of the scalp.

Arterial occlusion or constriction can occur when the dermal filler is lodged into the vessel or if too much pressure is placed around the vessels and they collapse.

Retrograde embolization can occur when the filler flows backwards into the ophthalmic artery. Blockage into the tiny vessels that feed the eyes can lead to visual impairment and in rare cases blindness.

Tip: When injecting the lateral brows, put a finger over the supraorbital arteries to prevent blockage and or retrograde embolization.

Danger Zone 3: Medial canthus/ medial angle to the eyes orbit

This is also a no-go zone because this is the area where the ophthalmic branch of the internal carotid artery and the angular artery of the external carotid which runs alongside the nose anastomoses in the inner part of the eye cavity.

The angular artery is the terminal branch of the facial artery and supplies blood to the medial cheeks and nose by its anastomosis to the dorsal nasal artery.

The dorsal nasal artery supplies the bridge of the nose but also has retrograde flow to the back of the eye connecting with the ophthalmic artery. Like the previous danger zones, blocking these vessels will compromise blood flow to the nose and or the eye.

Tip: avoid one finger breadth from the medial canthus (2 centimeters)

Danger Zone 4: Infraorbital Region and Nasojugal fold

This area can have noticeable volume loss related to the malar cheek fat pad or the “apple of the cheek”

The infraorbital foreman is in this region.  At periosteum, the foreman is anywhere from 5 to 11 mm inferior to the orbital ridge. This is where the infraorbital artery, vein and nerve exits. Infraorbital artery is one of the terminal branches of the maxillary artery. Branches of the infraorbital artery anastomosing with the dorsal nasal branch, facial artery and transverse artery which can all lead to complications to the nose and eyes of occluded or constricted.

This is a no-go zone at the level of periosteum. Avoid deep bolus injections.

Tip: inject lateral to the infraorbital foreman and avoid deep periosteum injections. Use a fanning technique within the medial and deep fat compartments.

Danger Zone 5: Nasal “liquid nose job”

Nasal Augmentation Is the main cause of nasal tissue necrosis and the second cause of visual loss after the glabella region.

The delicate communication between the external and internal carotid vascular network increases the danger of embolization in a retrograde flow towards the central retinal artery behind the eye. The dorsal nasal artery which has direct communications to the ophthalmic artery runs down the nose sometimes with just one branch and towards the lateral nasal artery that ascends from the facial artery.

Vessel constriction or occlusion can occur when these delicate vessels have too much pressure or occlusion within the artery resulting in alar or tip necrosis, ocular ischemia or blindness.

The entire nose get a no-go for fillers if it has had previous rhinoplasty. “Nose job”

Tip: The Nose gets a full finger breadth NO-GO Zone down both sides of the nose due to the angular artery and an extreme caution along the dorsum and tip.

Danger Zone 6: Lips/Oral commissure

As the facial artery makes its way from the mandible notch to the oral commissure, It branches to the inferior labial artery and the superior labial artery and continues towards the nasal alar and meets the angular artery.

The Inferior labial artery comes off the facial artery and penetrates the orbicularis oris and runs a tortuous course along the inferior “wet/dry” border. It supplies blood to the lower lip and mucous membrane. The artery anastomoses with the inferior labial artery on the opposite side.

The superior labial artery is larger than the inferior artery and runs along the inferior “wet” border. It has 2-3 branches towards nose including the alar branch and nasal septal.

Avoid injecting the wet/dry border on the lower and upper lip.

Avoid injecting perpendicular to the vermillion border unless vessel mapped and or aspirate

Tips: One fingerbreadth give or take lateral from the oral commissure lies the facial artery to avoid.

Danger Zone 7: Nasolabial fold and the Nasal Alar Groove

The facial artery gives off the inferior alar artery.  In some cases, the superior labial artery gives off the inferior alar making the branch at the ala more superficial. The facial artery then anastomoses into the angular artery at the nasal alar.

Extreme caution should be exercised when injecting near the alar groove because large amount of filler above or below could exceed the intravascular pressure limits and constrict blood flow.

Vessel occlusion of the facial artery or angular artery can occur with the limited collateral circulation to the nose and distal arteries to the eyes. 

Tip: Completely avoid one fingerbreadth posterior to the nasal alar and inject perpendicularly to the vessel.  The nasal ala is a NO-GO Zone

Side note: Aesthetically speaking filling in this area does not look natural to the human facial anatomy. Dermal filling in this area can create a simian look. “Monkey mouth”

Danger Zone 8. Mandible and Jawline
 

The facial artery branches from the external carotid artery, follows the inferior border of the mandible, and enters the face at the mandible notch anterior inferior portion of the masseter muscle.

It follows a very torturous course as it makes its way towards the oral commissure.

The facial artery is the largest artery in the face and as we have already seen plays a crucial function in maintaining oxygen rich blood flow to 16 muscles, with 8 branches including the branches that anastomose to the nose and eyes.

We don’t pay enough attention to where the facial artery enters the face at the mandible notch and the jawline is becoming a very popular area to restore volume and give structure to the jawline.

Tip: Inject perpendicular to the vessel, parallel to the bass of the mandible, aspirate and use vessel mapping.

Danger Zone 9   Anterior Medial Length of the Ear

The external carotid artery comes up from the neck of the mandible and divides into the maxillary artery and the slightly smaller superficial temporal artery.

The maxillary artery lies deep in the parotid gland. With its seventeen branches, it supplies blood to deep structures of the face. One of the branches is the infraorbital artery discussed earlier. 

Anterior to the maxillary along the lower boarder of the zygomatic arch lies the transverse facial artery. It runs transversely across the face which supplies the parotid gland and duct, skin, and masseter muscle. The vessel rests superior to the masseter muscle.

Avoid one fingerbreadth the entire length of the anterior border of the ear from base of mandible to superior temporal fossa.

Tip: When injecting in the mid face, inject one fingerbreadth below the zygomatic arch, perpendicular to the transverse facial artery, using a fanning technique. aspirate and avoid deep injections into the masseter or parotid gland.

Danger Zone 10: Temporal Fossa

Two major vessels to avoid are the superficial temporal artery and middle temporal vein.

The superficial temporal artery comes up from the external carotid and ascends in front of the ear to the temporal area where it splits into the parietal and frontal branches and supplies the surrounding muscles and skin of the scalp.

 If the superficial temporal artery is inadvertently injected, it has been shown that the dermal filler can travel to the back of the eyes via its connection with the supratrochlear artery.

The middle temporal vein drains into the jugular and can cause a distal pulmonary embolism if injected with dermal filler.

Use vessel mapping, locate arterial pulse, aspirate, avoid large high pressure bolus.

 Tip: Safest place to inject is one fingerbreadth above the superior border of the zygomatic arch with your finger posterior to the tail of the eyebrow to avoid the middle temporal vein.

CONCLUSION

All the areas discussed are connected in one way or another. Whether it be the flow from the facial artery to the angular artery to lateral and dorsal and nasal arteries connect to the ophthalmic artery to the central retinal artery.

Temporal flow to supratrochlear artery with the retrograde flow to the ophthalmic artery.

These ten zones are not exclusive. Anatomy is not the same for every person. There is no black and white text book for knowing exact locations.

This discussion mainly focused on the arterial system of the face. Extensive knowledge of veins, nerves, and glands are also crucial for patient safety.

 In-depth knowledge of facial anatomy using safety techniques such as vessel mapping, aspiration, knowing your depths, when you can bolus and when not, when to use a needle vs a cannula or visa versus are the keys to successfully injecting dermal fillers.

Asia Hankins RN
Queen of Liquid Facelifts™