Facial Danger Zones: Techniques to Maximize Safety during Soft-Tissue Filler Injections

Abstract

Given the short recovery and immediate results, facial fillers have become a popular alternative to surgical rejuvenation of the face. Reported complications arising from facial filler injections include erythema, tissue loss, blindness, stroke, and even death. In this article, the authors describe their anatomically based techniques to minimize risk and maximize safety when injecting in the facial danger zones, including the glabella/brow, temporal region, perioral region, nasolabial fold, nose, and infraorbital region. Complications generally arise secondary to vasculature injury and/or cannulation with filler. The authors have outlined their preferred injection techniques in the facial danger zones with respect to the pertinent anatomy in an attempt to minimize risk and maximize results. Most importantly, the practitioner should be able to recognize complications and address them immediately.

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“…Attention should be paid to danger zones, described by several experts; in a recent publication the authors focused on the glabella/ brow, temporal region, perioral region, nasolabial fold, nose and infraorbital region and proposed techniques to maximize safety. 106 Lips, glabella and periorbital region (eyelids, under-eye dark circles, crow's feet) have to be avoided with the PCL filler as generally with collagen stimulators.…”

“…Good knowledge of anatomy, and particularly of the danger zones, is needed. 106,125 Time is short for the physician to intervene; prompt recognition of the problem, particularly appearance of pain, skin discoloration allows treatment to be stopped and complication treatment started immediately; topical nitropaste under occlusive dressing, high dose of hyaluronidase, oral acetylsalicylic acid (aspirin), warm compresses and vigorous massage have been recommended; secondary lines of treatment may involve hyperbaric oxygen therapy and ancillary vasodilating agents such as prostaglandin E1. [126][127][128] A metanalysis of vascular complications of facial fillers provides an interesting update.…”

The Bipedicled Orbicularis Oculi Myocutaneous Flap for the Repair of Paralytic Ectropion

“…First, although the authors present the rabbit and human ophthalmic vascular systems as being similar, it should be noted that some critical differences exist. [2][3][4][5] The human system does not have an external ophthalmic artery originating from the external carotid artery. The long ciliary arteries in the rabbit form a route of connection between this auxiliary artery and the internal ophthalmic artery.…”

“…[1][2][3] Surgical correction has traditionally been accomplished with eyelid shortening and repositioning, but recurrence of ectropion in paralytic eyelid syndrome remains high. 4 We describe a new surgical approach to paralytic eyelid syndrome, the bipedicled orbicularis oculi myocutaneous flap. It is a modification of the full-thickness upper eyelid flap, originally described by Anderson and Weinstein 5 for reconstruction of defects of the lower eyelid.…”

Safety in the Use of Fillers in Nasal Augmentation—the Liquid Rhinoplasty

“…The level of injection must be deep and midline to maximize safety and to avoid both skin loss and potential blindness. 2 To minimize the risk of intravascular injection, one must take into consideration the subcutaneous location of the nasal vessels superficial to the nasal muscles along with the rich plexus of vessels, with contributions from the angular, supraorbital, and supratrochlear arteries. ( See Video 1 [online] , which displays the arterial anatomy around the nose as well as a patient who is receiving nonsurgical nasal augmentation, including a neuromodulator injection into the depressor septi nasi.)…”