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

Dorsal Nasal Artery and Dermal Filler Safety

Critical Safety Recommendation

Use strict intradermal injection technique with 30-gauge needles at shallow angles, creating visible papules to confirm superficial placement and avoid the dorsal nasal artery, which connects directly to the ophthalmic artery and poses catastrophic blindness risk. 1, 2

Understanding the Vascular Anatomy

The dorsal nasal artery is a terminal branch of the ophthalmic artery that anastomoses with facial artery branches, creating a direct pathway for retrograde embolization to the ophthalmic circulation. 2 This anatomical connection explains why nasal filler injections can cause sudden blindness—injected material can travel backward through these connections into the retinal artery. 2

Variable Arterial Anatomy Requires Caution

• 80% of patients have the expected lateral arterial pathway along the nasal sidewalls, but 20% have midline dorsal nasal artery coursing directly where fillers are commonly injected. 3
• In 8% of cases, the artery travels just beneath the preperiosteal layer (under the nasalis muscle), and in 14% it courses superficially just beneath the subdermal layer. 3
• This unpredictable anatomy means you cannot rely on "standard" injection planes—every patient has unique vascular distribution. 3

Mandatory Injection Protocol

Layer Selection is Life-or-Death Critical

Inject exclusively in the intradermal layer using 30-gauge, 4mm needles with the bevel facing upward. 4, 1 The formation of a visible papule with blanching confirms you are in the dermis and NOT in the hypodermis where the dorsal nasal artery resides. 4, 1

• Never inject into the sub-SMAS layer or preperiosteal layer on the nasal dorsum—these deeper planes have direct contact with the dorsal nasal artery and angular artery. 2
• Even "safe" preperiosteal injections carry vascular compromise risk despite being commonly recommended. 3

Specific Technical Requirements

• Aspirate before every single injection to detect intravascular needle placement. 4, 5
• Use incremental small-volume injections (maximum 0.2-0.5 mL per site) rather than boluses to allow early complication detection. 4, 5
• Inject in retrograde fashion while withdrawing the needle to minimize intravascular injection risk. 5
• Create visible wheals 6-10mm in diameter to prove intradermal placement. 1

Advanced Safety Measures

Pre-Injection Vascular Mapping

Consider Doppler ultrasound mapping of the dorsal nasal artery before injection, particularly in high-risk patients or revision cases. 6 Ultrasound can detect the dorsal nasal artery's exact location and depth, revealing the 20% of patients with midline arterial anatomy. 3, 6

Cannula Consideration with Critical Caveat

While large-diameter blunt cannulas are suggested for nasal augmentation, 3 understand that even cannula injection into the preperiosteal layer carries vascular compromise risk. 3 If using cannulas, maintain the same intradermal plane and avoid deep injection. 5

Safer Alternative for Specific Indications

For patients seeking nasal refinement without significant volumization, consider autologous platelet concentrates (APCs) instead of hyaluronic acid fillers. 4, 1, 5

• APCs provide skin quality improvement and fine line reduction with intradermal 30-gauge needle injection at 0.25mm depth. 4, 5
• Effects last only 3-4 months versus longer-lasting traditional fillers, but carry potentially lower vascular catastrophe risk. 1, 5
• APCs are appropriate for rejuvenation but NOT for structural augmentation or significant dorsal height increase. 1

Common Pitfalls to Avoid

The most dangerous error is assuming the "safe plane" exists—it doesn't. 3, 2 The dorsal nasal artery's variable anatomy means:

• Deep periosteal injections risk the 8% of patients with deep arterial anatomy. 3
• Superficial subdermal injections risk the 14% with superficial arterial anatomy. 3
• Only true intradermal technique with visible papule formation provides consistent safety. 1

Never inject large volumes rapidly—this increases intravascular pressure and embolization risk even if you're not directly in the vessel. 4, 5

High-Risk Zone Recognition

The nasal dorsum ranks among the three highest-risk areas for ophthalmic artery embolism (along with glabella and nasolabial fold). 2, 6 Treat every nasal injection as potentially vision-threatening and maintain heightened vigilance for immediate complications including vision changes, severe pain, or skin blanching. 2