What precautions should be taken when administering dermal fillers near the supratrochlear and supraorbital arteries?

Supratrochlear and Supraorbital Artery Safety with Dermal Fillers

When injecting dermal fillers near the supratrochlear and supraorbital arteries, use only intradermal placement with 30-gauge needles at shallow angles, creating visible 6-10 mm wheals to confirm superficial placement, and avoid deep periosteal injections entirely to prevent catastrophic retrograde embolization to the ophthalmic artery causing blindness. 1, 2

Critical Vascular Anatomy and Risk

The supratrochlear and supraorbital arteries are direct branches of the ophthalmic artery and represent the highest-risk vessels for vision-threatening complications during facial filler injections. 3, 4

Key anatomical facts:

• The supratrochlear artery has an average volume of only 0.085 mL from the glabella to the orbital apex, meaning even small bolus injections can cause retrograde flow to the central retinal artery. 5
• These arteries course at a mean depth of 3.34 mm (supratrochlear) and 3.54 mm (supraorbital) from the skin surface. 6
• The supratrochlear artery is located approximately 8-11 mm lateral to the vertical glabellar line, and this position shifts medially by 1.6-1.8 mm during frowning. 6
• Deep periosteal injections in the glabellar region directly risk injuring these vessels, while sub-SMAS injections pose similar risks in the nasal dorsum. 4

Mandatory Injection Technique Protocol

Layer selection is critical:

• Use intradermal placement ONLY—never inject deeply near the supraorbital or supratrochlear regions. 1
• Inject above the orbicularis oculi muscle to remain superficial to major vessels. 1
• Avoid periosteal layer injections in the glabellar region entirely, as this is where the supratrochlear and supraorbital arteries are most vulnerable. 4

Needle and cannula specifications:

• Use 30-gauge needles with shallow insertion angles, targeting only the dermis layer. 1, 2
• Consider 22-25 gauge blunt-tip cannulas for enhanced safety when treating the periorbital area. 1
• Create visible wheals or papules (6-10 mm diameter) to confirm proper intradermal placement and avoid deeper vasculature. 1, 2

Volume and injection technique:

• Limit treatment volume to 0.2-0.5 mL maximum per injection site in high-risk zones. 1
• Aspirate before every single injection to detect intravascular needle placement. 1, 2
• Use incremental small-volume injections rather than large boluses to allow early complication detection. 1, 2
• Inject in retrograde fashion while withdrawing the needle. 1

Common Pitfalls to Avoid

The vertical glabellar line is NOT a safe landmark:

• The supratrochlear artery does not consistently course deep to the vertical glabellar crease—it is typically 8-11 mm lateral to this line and can shift position with facial movement. 6
• Injecting "next to the vertical glabellar line" is not inherently safe and should not be relied upon as a protective strategy. 6

Deep injection is the primary risk factor:

• The highest index of vascular complications and visual alterations occurs with fillings in the upper third of the face, particularly the glabellar and supraorbital regions. 3
• Deep periosteal injections place the needle directly in the path of the supratrochlear and supraorbital arteries. 4

Alternative Approach for High-Risk Patients

Consider autologous platelet concentrates (APCs) instead of hyaluronic acid fillers:

• APCs provide skin quality improvement, reduced hyperpigmentation, and wrinkle reduction with lower vascular risk when volumization is not the primary goal. 1, 7
• Use 30G needles at 0.25 mm depth for intradermal injection in the periorbital area. 1, 7
• APCs do not provide lasting volumization (effects last only 3 months) but offer rejuvenation with potentially lower complication rates. 1, 7
• Three treatments spaced at minimum 21-day intervals are typically required, with maintenance every 6 months. 7

Arterial Distribution Patterns

Understanding forehead vascular anatomy:

• Two main arterial distribution patterns exist based on the presence of a deep branch of the supratrochlear artery. 8
• In Type I patterns, both superficial and deep branches supply the forehead, with the deep branch of the supratrochlear artery and deep branch of the supraorbital artery distributed deep to the frontalis muscle. 8
• In Type II patterns, only the deep branch of the supraorbital artery supplies the layer deep to the frontalis. 8
• This variability means that no single injection depth is universally safe—intradermal placement remains the only consistently safe approach. 8