What precautions should be taken when using dermal fillers, such as Juvederm (hyaluronic acid) or Restylane (hyaluronic acid), near the infraorbital artery?

Infraorbital Artery and Dermal Filler Safety

When injecting dermal fillers near the infraorbital artery, use superficial intradermal placement with small gauge needles (30G), avoid the medial infraorbital region where the artery is most concentrated, and aspirate before every injection to prevent catastrophic vascular occlusion that can lead to blindness.

Critical Vascular Anatomy

The infraorbital artery poses the highest risk for severe complications in facial filler procedures, particularly in the upper third of the face 1, 2.

• The infraorbital artery has an 81% probability of being identified at the medial infraorbital location (C2 position), making this the highest-risk zone 2
• The infraorbital artery is a major branch of the maxillary artery that supplies the lower eyelid, cheek, and connects to the ophthalmic artery system 3, 1
• Arterial occlusion in this region can cause retrograde flow into the ophthalmic artery, resulting in permanent blindness 4, 5

Specific Injection Technique to Minimize Risk

Depth and Needle Selection

Use intradermal placement only—never inject deeply near the infraorbital region 6.

• Use 30-gauge needles with shallow insertion angles, targeting only the dermis layer 6
• Create visible wheals or papules (6-10 mm diameter) to confirm proper intradermal placement and avoid deeper vasculature 6
• Inject above the orbicularis oculi muscle to stay superficial to major vessels 7
• Consider 22-25 gauge cannulas for blunt-tip safety when treating the periorbital area 3, 7

Location-Based Risk Stratification

The lateral infraorbital region (P4 segment) has the lowest arterial density with only 18.4% probability of encountering vessels, making it the safest injection zone 2.

• Avoid the medial infraorbital area where arterial concentration is highest 2
• The upper third of the face, including the infraorbital and supraorbital regions, has the highest index of vascular complications and visual alterations 1
• Minimize treatment volume in high-risk zones—use 0.2-0.5 mL maximum per injection site 7

Mandatory Safety Protocol

Aspirate before every single injection to detect intravascular needle placement 6.

• Use incremental small-volume injections rather than large boluses to allow early complication detection 6
• Inject in retrograde fashion while withdrawing the needle 7
• Stop immediately if blanching, severe pain, or vision changes occur—these indicate arterial compromise 4, 8

Common Complications in the Infraorbital Region

Expected Minor Complications

• Ecchymosis, malar edema, and mild swelling are the most common effects and typically self-resolve 7, 8
• Blue-gray hue (Tyndall effect) and contour irregularities occur with superficial placement 8
• Warn all patients preoperatively about bruising and swelling, which are nearly universal 7

Catastrophic Vascular Complications

Arterial occlusion from infraorbital filler injection can cause skin necrosis and permanent blindness 4, 5.

• Visual loss occurs when filler enters the infraorbital artery and travels retrograde to the ophthalmic artery 4
• Even immediate intra-arterial hyaluronidase infusion may not restore vision once ophthalmic artery occlusion occurs 4
• Skin necrosis results from direct arterial occlusion or compression of perforating vessels 8, 5

Emergency Management Considerations

If vascular occlusion is suspected:

• Have hyaluronidase immediately available (1500 units for hyaluronic acid fillers) 4
• Facial artery branches may respond to hyaluronidase, but ophthalmic artery occlusion often results in permanent damage despite treatment 4
• This underscores why prevention through proper technique is paramount—treatment of established complications has limited efficacy 4, 5

Alternative Approach for High-Risk Patients

Consider autologous platelet concentrates (APCs) instead of hyaluronic acid fillers for periorbital rejuvenation when volumization is not the primary goal 3, 9.

• APCs provide skin quality improvement, reduced hyperpigmentation, and wrinkle reduction with lower vascular risk 3
• Use 30G needles at 0.25 mm depth for microneedling or intradermal injection in the periorbital area 3
• APCs do not provide lasting volumization (effects last only 3 months) but offer rejuvenation with potentially lower complication rates 7, 9

Critical Pitfalls to Avoid

• Never inject deeply in the infraorbital region—stay strictly intradermal 6, 1
• Never inject large volumes in a single bolus near the infraorbital artery 6
• Never proceed without aspirating first 6
• Do not dismiss early warning signs like blanching, pain, or vision changes 4, 8
• Avoid the medial infraorbital zone entirely if possible, as this has 81% arterial presence 2