MD CODES Cheek Injection Safety: Blood Vessels to Avoid and Injection Depth
For cheek enhancement using MD CODES, inject at the deep subcutaneous to supraperiosteal plane, staying lateral to a danger zone extending 15mm from the oral commissure and 7mm from the nasal ala, where the facial artery courses at approximately 11-12mm depth.
Critical Vascular Anatomy to Avoid
Facial Artery Location and Danger Zones
The facial artery crosses the nasolabial fold in 33.9% of cases and ascends within 5mm of the nasolabial fold in an additional 42.9% of cases, making this a high-risk zone for vascular complications 1
Maximum risk of arterial injury occurs approximately 15mm lateral to the oral commissure at a depth of 11mm, with the facial artery diameter measuring 2.6 ± 0.8mm at this level 2
At the lateral nasal ala, the facial artery is located approximately 7mm laterally at a depth of 12mm, with a diameter of 1.9 ± 0.5mm 2
The infraorbital artery must be avoided in the midcheek region, as injections near this vessel carry significant risk of serious complications including blindness and necrosis 3
Detoured Branch Patterns
Detoured branches of the facial artery occur in 30% of cases, turning medially over the infraorbital area at 39.2 ± 5.8mm lateral to the facial midsagittal line and 35.2 ± 8.2mm inferior to the plane connecting the medial epicanthi 1
The nasojugal portion of detoured branches travels along the inferior border of the orbicularis oculi before ascending toward the forehead to form the angular artery 1
Optimal Injection Depth and Technique
Recommended Injection Plane
Inject at the deep subcutaneous to supraperiosteal plane to minimize risk of intravascular injection while achieving optimal volumization and structural support 3
The midface is considered an advanced treatment area, requiring specific training particularly when injecting near the nose due to risk of blindness and necrosis 3
Critical Safety Considerations
Hyaluronic acid and autologous fat are the two fillers most frequently involved in vascular occlusions, with autologous fat showing a stronger trend toward no improvement compared to HA 4
Injury to ophthalmic and retinal arteries results in irreversible serious adverse events in 72% of cases, with blindness being the main consequence in 61% of vascular complications 4
The arterial supply of the face exhibits high variability in branching patterns, course, and depth, making it impossible to absolutely guarantee safety during injectable procedures 5
MD CODES Active Numbers for Cheek Enhancement
Injection Points and Depths
Inject lateral to the danger zones (>15mm from oral commissure, >7mm from nasal ala) to avoid the facial artery's predictable course 1, 2
Maintain injection depth superficial to 11-12mm when working near the nasolabial fold and lateral nasal ala to stay above the facial artery 2
Use caution in the infraorbital area, staying lateral and avoiding medial trajectories that could encounter detoured arterial branches 1
Common Pitfalls and How to Avoid Them
Never inject perpendicular to the nasolabial fold within 5mm of its visible crease, as the facial artery crosses or runs adjacent to this area in 76.8% of cases 1
Avoid deep injections (>11mm) in the 15mm zone lateral to the oral commissure, as this is the maximum risk area for facial artery injury 2
Do not assume consistent vascular anatomy between patients or even between sides of the same face, as branching patterns show high individual variability 5
Always aspirate before injection and inject slowly with low pressure to detect intravascular placement and allow time to stop if complications arise 4, 5