Official reprint from UpToDate®
www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Anatomic danger zones for facial injection of soft tissue fillers

Shawn Allen, MD
Section Editor
Jeffrey S Dover, MD, FRCPC
Deputy Editor
Rosamaria Corona, MD, DSc


Complications associated with the injection of soft tissue fillers arise in most cases from injector inexperience or use of unapproved products. However, injection injuries to relevant anatomic structures, such as nerves and vessels, can occur even in the hands of experienced injectors while using US Food and Drug Administration (FDA)-approved products.

The incidence of vascular occlusion following soft tissue injection may be as high as 3 in 1000 [1]. In May 2015, the US FDA warned that the unintentional injection of soft tissue fillers into the blood vessels of the face can result in rare but serious adverse effects and advised providers without appropriate training or experience to refrain from injecting soft tissue fillers [2].

This topic will review the relevant vascular anatomy of the face and the danger zones at risk of vascular compromise from injection of soft tissue filers. The types and clinical use of injectable soft tissue fillers are discussed separately. The anatomic danger zones for cutaneous surgery of the head and neck are also reviewed separately.

(See "Injectable soft tissue fillers: Overview of clinical use".)

(See "Injectable soft tissue fillers: Temporary agents".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Dec 2017. | This topic last updated: Jul 05, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2018 UpToDate, Inc.
  1. Beleznay K, Humphrey S, Carruthers JD, Carruthers A. Vascular compromise from soft tissue augmentation: experience with 12 cases and recommendations for optimal outcomes. J Clin Aesthet Dermatol 2014; 7:37.
  2. Unintentional Injection of Soft Tissue Filler into Blood Vessels in the Face: FDA Safety Communication. www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm448255.htm (Accessed on February 16, 2016).
  3. Lazzeri D, Agostini T, Figus M, et al. Blindness following cosmetic injections of the face. Plast Reconstr Surg 2012; 129:995.
  4. Park SW, Woo SJ, Park KH, et al. Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections. Am J Ophthalmol 2012; 154:653.
  5. DeLorenzi C. Complications of injectable fillers, part I. Aesthet Surg J 2013; 33:561.
  6. Brennan C. Avoiding the "danger zones" when injecting dermal fillers and volume enhancers. Plast Surg Nurs 2014; 34:108.
  7. Sykes JM, Cotofana S, Trevidic P, et al. Upper Face: Clinical Anatomy and Regional Approaches with Injectable Fillers. Plast Reconstr Surg 2015; 136:204S.
  8. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 1986; 77:17.
  9. Jung W, Youn KH, Won SY, et al. Clinical implications of the middle temporal vein with regard to temporal fossa augmentation. Dermatol Surg 2014; 40:618.
  10. Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: an important reference point for surgery in the temporal region. Plast Reconstr Surg 1998; 101:27.
  11. Moradi A, Shirazi A, Perez V. A guide to temporal fossa augmentation with small gel particle hyaluronic acid dermal filler. J Drugs Dermatol 2011; 10:673.
  12. Goldberg RA, Wu JC, Jesmanowicz A, Hyde JS. Eyelid anatomy revisited. Dynamic high-resolution magnetic resonance images of Whitnall's ligament and upper eyelid structures with the use of a surface coil. Arch Ophthalmol 1992; 110:1598.
  13. Saban Y, Andretto Amodeo C, Bouaziz D, Polselli R. Nasal arterial vasculature: medical and surgical applications. Arch Facial Plast Surg 2012; 14:429.
  14. Ozturk CN, Li Y, Tung R, et al. Complications following injection of soft-tissue fillers. Aesthet Surg J 2013; 33:862.
  15. Cotofana S, Schenck TL, Trevidic P, et al. Midface: Clinical Anatomy and Regional Approaches with Injectable Fillers. Plast Reconstr Surg 2015; 136:219S.
  16. Pereira OJ, Bins-Ely J, Granemann AS, Lee KH. Correction of inverted nipples by strong suspension with areola-based dermal flaps. Plast Reconstr Surg 2009; 123:1132; author reply 1132.
  17. Kim YS, Choi DY, Gil YC, et al. The anatomical origin and course of the angular artery regarding its clinical implications. Dermatol Surg 2014; 40:1070.
  18. Marur T, Tuna Y, Demirci S. Facial anatomy. Clin Dermatol 2014; 32:14.
  19. Braz A, Humphrey S, Weinkle S, et al. Lower Face: Clinical Anatomy and Regional Approaches with Injectable Fillers. Plast Reconstr Surg 2015; 136:235S.
  20. Rzany B, DeLorenzi C. Understanding, Avoiding, and Managing Severe Filler Complications. Plast Reconstr Surg 2015; 136:196S.
  21. Yang HM, Lee JG, Hu KS, et al. New anatomical insights on the course and branching patterns of the facial artery: clinical implications of injectable treatments to the nasolabial fold and nasojugal groove. Plast Reconstr Surg 2014; 133:1077.
  22. www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/CosmeticDevices/WrinkleFillers/ucm227749.htm (Accessed on June 22, 2016).
  23. DeLorenzi C. Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J 2014; 34:584.
  24. Beleznay K, Carruthers JD, Humphrey S, Jones D. Avoiding and Treating Blindness From Fillers: A Review of the World Literature. Dermatol Surg 2015; 41:1097.
  25. Beer K, Downie J, Beer J. A treatment protocol for vascular occlusion from particulate soft tissue augmentation. J Clin Aesthet Dermatol 2012; 5:44.
  26. Kim DW, Yoon ES, Ji YH, et al. Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in management. J Plast Reconstr Aesthet Surg 2011; 64:1590.
  27. Goodman GJ, Clague MD. A Rethink on Hyaluronidase Injection, Intraarterial Injection, and Blindness: Is There Another Option for Treatment of Retinal Artery Embolism Caused by Intraarterial Injection of Hyaluronic Acid? Dermatol Surg 2016; 42:547.
  28. Schwenn OK, Wüstenberg EG, Konerding MA, Hattenbach LO. Experimental percutaneous cannulation of the supraorbital arteries: implication for future therapy. Invest Ophthalmol Vis Sci 2005; 46:1557.
  29. Megías-Vericat JE, Ricart JM, Ribes-Artero H, Poveda JL. Prostaglandin Injection After Arterial Compromise Related to Hyaluronic Acid Filler. Dermatol Surg 2017; 43:975.
  30. Kim SG, Kim YJ, Lee SI, Lee CJ. Salvage of nasal skin in a case of venous compromise after hyaluronic acid filler injection using prostaglandin E. Dermatol Surg 2011; 37:1817.
  31. Hwang CJ, Morgan PV, Pimentel A, et al. Rethinking the Role of Nitroglycerin Ointment in Ischemic Vascular Filler Complications: An Animal Model With ICG Imaging. Ophthal Plast Reconstr Surg 2016; 32:118.
  32. Darling MD, Peterson JD, Fabi SG. Impending necrosis after injection of hyaluronic acid and calcium hydroxylapatite fillers: report of 2 cases treated with hyperbaric oxygen therapy. Dermatol Surg 2014; 40:1049.
  33. Yeh LC, Fabi SG, Welsh K. Arterial Penetration With Blunt-Tipped Cannulas Using Injectables: A False Sense of Safety? Dermatol Surg 2017; 43:464.
  34. Hexsel D, Soirefmann M, Porto MD, et al. Double-blind, randomized, controlled clinical trial to compare safety and efficacy of a metallic cannula with that of a standard needle for soft tissue augmentation of the nasolabial folds. Dermatol Surg 2012; 38:207.