What are the precautions and risks associated with injecting dermal fillers near the facial artery?

Facial Artery and Dermal Fillers: Critical Safety Precautions

When injecting dermal fillers near the facial artery, use intradermal technique with 30-gauge needles at shallow angles to avoid vascular injury, as vascular occlusion represents the most catastrophic complication leading to tissue necrosis, blindness, and stroke. 1, 2

Understanding the Vascular Risk

The facial artery and its branches pose significant danger during filler injections because direct intravascular injection or arterial compression can cause devastating complications. Vascular occlusion during filler injection results in no improvement in 72% of cases, with blindness being the most common severe outcome (61% of vascular complications). 2 The upper third of the face, particularly the glabellar and nasal regions, carries the highest risk for vascular injury and visual complications. 3

High-Risk Anatomical Zones

• The glabella, nasal region, and supraorbital areas represent the most dangerous injection sites due to proximity to ophthalmic and retinal arteries, which when injured show the strongest association with irreversible complications. 3, 2
• The temporal region, infraorbital area, nasolabial folds, and perioral regions also contain critical vascular structures requiring heightened caution. 4, 5
• Injury to ophthalmic and retinal arteries during facial filler injection most frequently results in permanent visual loss with no improvement. 2

Evidence-Based Safety Protocol

Injection Technique

Use intradermal injection technique with 30-gauge, 4mm needles inserted at shallow angles with the bevel facing upward to target only the dermal layer. 1 This approach is critical because:

• Intradermal placement creates a visible wheal or papule 6-10mm in diameter, confirming proper superficial placement. 1
• The formation of a papule with blanching during injection confirms intradermal placement and avoids placing product into deep underlying vasculature. 1
• Shallow insertion angles prevent penetration into the hypodermis where major vessels reside. 1

Pre-Injection Precautions

• Aspirate the needle prior to each injection to avoid introducing filler directly into a vessel, as recommended for preventing local anesthetic systemic toxicity but equally applicable to filler safety. 6
• Use incremental injections rather than large boluses to minimize vascular compression and allow early detection of complications. 6
• Maintain detailed knowledge of facial vascular anatomy, as most serious adverse events are avoidable with proper planning and technique. 7, 4

Material-Specific Considerations

Autologous fat shows a stronger trend toward no improvement after vascular occlusion compared to hyaluronic acid fillers. 2 This is clinically significant because:

• Hyaluronic acid complications can potentially be reversed with hyaluronidase, while fat embolization cannot be reversed. 2
• Both hyaluronic acid and autologous fat are the two fillers most frequently involved in vascular occlusions. 2

Critical Pitfalls to Avoid

• Never inject deeply in the upper third of the face (glabellar, nasal, supraorbital regions) where the risk-benefit ratio is unfavorable. 3
• Avoid high-volume injections that increase risk of arterial compression. 7
• Do not proceed without the ability to recognize and immediately address vascular compromise. 4
• Most complications are related to volume and technique rather than the material itself, emphasizing the importance of proper injection methodology. 7

Recognition and Response

Practitioners must be able to immediately recognize signs of vascular compromise including:

• Sudden severe pain during injection
• Immediate blanching or mottling of skin
• Visual changes or eye pain (indicating ophthalmic artery involvement)

Have hyaluronidase immediately available when using hyaluronic acid fillers, as rapid administration represents the only potential reversal option for HA-related vascular occlusion. 7, 5