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Articulo Videp
Articulo Videp
G
iven the short recovery and immediate and maximize safety when injecting in the facial
results, facial fillers have become a popu- danger zones (Table 1).
lar alternative to surgical rejuvenation
of the face. For the past 6 years, filler injections
Technique for Safety in the
have ranked behind only botulinum toxin injec-
tions for the most popular nonsurgical cosmetic Glabella and Brow
procedure.1 Given current trends, it becomes The supraorbital, supratrochlear, dorsal
all the more important that practitioners learn nasal, and angular arteries anastomose in the
safe, predictable techniques to achieve optimal nasoglabellar region to form a vascular arcade.
results with facial filler injections. (See Video, Given the rich network, it becomes obvious how
Supplemental Digital Content 1, which identifies intravascular cannulation can create retrograde
the facial danger zones and demonstrates how to propagation of a foreign body to the ophthalmic
safely inject facial fillers in these areas, available in artery. The arteries quickly become superficial
the “Related Videos” section of the full-text article after exiting the orbit and closely abut rhytides,
on PRSJournal.com or, for Ovid users, available at especially the supratrochlear artery and the gla-
http://links.lww.com/PRS/C132.) bellar frown lines.2 Therefore, we recommend
Reported complications arising from facial
filler injections include erythema, tissue loss,
blindness, stroke, and even death. The most Disclosure: The authors have no financial interests
severe complications generally occur secondary in this research project or in any of the techniques or
to inadvertent damage or cannulation of vascula- equipment used in this study. Dr. Rohrich receives
ture. Generally, we use only hyaluronic acid fillers instrument royalties from Eriem Surgical, Inc., and
except on rare occasions. Hyaluronic acid fillers book royalties from Thieme Medical Publishers. No
can be reversed with hyaluronidase, increasing funding was received for this article.
their safety profile. In this article, we describe our
anatomically based techniques to minimize risk
Supplemental digital content is available for
this article. Direct URL citations appear in the
From the Dallas Plastic Surgery Institute and Sieber Plastic text; simply type the URL address into any Web
Surgery. browser to access this content. Clickable links
Received for publication April 25, 2016; accepted October to the material are provided in the HTML text
5, 2016. of this article on the Journal’s website (www.
Copyright © 2017 by the American Society of Plastic Surgeons PRSJournal.com).
DOI: 10.1097/PRS.0000000000003309
www.PRSJournal.com 1103
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • May 2017
dermal injections into the offending rhytides with 0.5% lidocaine with epinephrine. Starting
with a low-G′ filler using a serial puncture tech- at the pretrichial line, the injection proceeds
nique. When injecting in the brow area, digital lateral to medial in the superficial subcutane-
pressure should be used to occlude the supra- ous plane just below the dermis. (See Video,
orbital and supratrochlear vessels along the rim Supplemental Digital Content 3, which dem-
to prevent backflow in the event of inadvertent onstrates a technique for safely injecting facial
injection of the vasculature. (See Video, Supple- fillers in the temporal region, available in the
mental Digital Content 2, which demonstrates “Related Videos” section of the full-text article
a technique for safely injecting facial fillers in on PRSJournal.com or, for Ovid users, available
the glabella and brow, available in the “Related at http://links.lww.com/PRS/C134.) In the tem-
Videos” section of the full-text article on PRS- poral region, the superficial temporal artery
Journal.com or, for Ovid users, available at resides in the temporoparietal fascia. How-
http://links.lww.com/PRS/C133.) It is extremely ever, as the vessel approaches the lateral bor-
important not to err too deep. The vessels can der of the frontalis, just above the brow peak, it
easily be lacerated by improper technique and
becomes subcutaneous. The needle should be
compressed by adjacent filler given their over-
in constant motion, injecting anterograde and
all smaller size. An intravascular injection in this
area can be devastating, leading to vision loss retrograde to displace any vasculature that may
and/or tissue necrosis. be encountered and to minimize the chance of
intravenous/intraarterial injection. Strong con-
sideration should be given to a cannula to lessen
Technique for Safety in the the chance of vessel puncture. Turning the
Temporal Region patient’s head medially helps highlight superfi-
To maximize safety when injecting in this cial veins, which can then be avoided. Filler can
area, we generally mix the filler at a 1:1 ratio then be massaged around the vessels to provide
1104
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 139, Number 5 • Safety in Filler Injections
an even fill. Although it is not our preferred Technique for Safety in the
method, the injection can also be performed Infraorbital Region
deep at the preperiosteal level. The filler can Overall, when injecting deep into the mid-
then be manipulated by massage to fill deficient face, measurements should be kept in mind to
areas. Naturally, a larger amount of filler will be avoid intravascular cannulation or vascular injury.
required when injecting at this level to transmit Generally, the infraorbital foramen will be located
the gains superficially. The middle temporal approximately 33 to 40 percent of the distance
vein runs approximately 2 cm above and paral-
between the medial and lateral canthi up to
lel to the zygomatic arch.3 Thus, deep injections
11 mm below the infraorbital rim.4–10 Clinically,
should be performed within a fingerbreadth of
it is generally in the vertical plane of the medial
the arch or at least several centimeters above it.
limbus, or immediately lateral, slightly less than
Finally, the frontal branch of the artery can still
be injured if it is lacerated by a needle going one fingerbreadth below the orbital rim. We avoid
from superficial to deep. direct deep injections into this area, going just lat-
eral. Injections more medial, especially approach-
ing the medial canthus, should be avoided
completely. If filler is needed in this area, it can be
injected deep laterally and pushed medially. (See
Video, Supplemental Digital Content 4, which
demonstrates a technique for safely injecting
facial fillers in the infraorbital region, available in
the “Related Videos” section of the full-text article
on PRSJournal.com or, for Ovid users, available at
http://links.lww.com/PRS/C135.)
1105
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • May 2017
1106
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 139, Number 5 • Safety in Filler Injections
1107
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • May 2017
1108
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.