Facial Danger Zones: Safe Injection Techniques for the Nasal and Infraorbital Regions Nasal Region

The Understanding facial vascular anatomy is essential to avoiding serious complications during aesthetic filler injections. This detailed guide examines the nasal and infraorbital areas—two of the most intricate and high-risk regions.

Discover key safety principles, preferred filler types, anatomical landmarks, and emergency protocols to minimize vascular compromise and ensure patient safety. Ideal for injectors dedicated to precision, safety, and anatomy-informed practice.

Many patients prefer to enhance their nose’s appearance without surgery, which can be achieved through the injection of soft-tissue fillers in a procedure known as liquid rhinoplasty.

However, because the nasal area is highly vascular, it is crucial to use a safe technique that prevents injury. The most important aspect of this method is injecting the filler deep into the tissue.

Key Points

When considering fillers, hyaluronic acid fillers are recommended because they can be reversed with hyaluronidase if needed. To avoid delayed swelling, using less hydrophilic filler is advisable. During injection, use small amounts with serial threading and massage the area after each infusion.

The serial puncture technique is preferred for the nasal tip and ala. Lateral injections should be performed carefully and superiorly to the alar groove. However, it is crucial to avoid injecting into the alar groove area at any layer, as this may damage the lateral nasal artery.

When injecting in the midline area of the nose, it is vital to use a deep plane to reduce the risk of injury to superficial blood vessels. If you aim to widen the internal nasal valve, only perform small, deep injections in the mid-vault.

Avoid injecting along the alar rim or nasal sidewall, as these areas contain numerous superficial blood vessels. Lastly, if you inject near the dorsal nasal or angular arteries, apply pressure to compress them during the procedure.

It is essential to exercise caution when treating patients with a history of rhinoplasty, as scarring may have altered the anatomical planes. The facial artery ascends to become the angular artery and gives off several significant branches, including the lateral nasal artery and the inferior alar artery.

The dorsal nasal arteries are positioned laterally to the midline along the nose’s dorsum. The inferior alar artery, which runs along the base of the nose, originates from the facial artery.

Additionally, during an open rhinoplasty, the columellar artery is dissected as a branch of the inferior alar artery.

Guidelines For Performing Injections in the Nasal Area to Avoid Injuring Arteries

1. The marginal artery runs along the surface of the alar rim.
2. Injections should be performed in a deep midline from the radix to the supra-tip break to avoid intravascular injection.
3. If injections are performed laterally, they should be done deeply at the midpoint and the Nasofacial groove to prevent inadvertent injury to the dorsal nasal artery and angular artery.
4. Injections in a superficial plane lateral to the midline can risk the dorsal nasal artery.
5. Injections in a superficial plane along the nasal sidewall can put the angular artery at risk.
6. Injections in a superficial plane along the alar groove can compromise the lateral nasal artery.
7. Superficial injections in the midline of the tip can injure the columellar artery.

Safety Considerations

The nose is composed of multiple layers, which are the epidermis, dermis, subcutaneous fat, muscle, fascia, areolar tissue, perichondrium/periosteum, and cartilage/bone. The vasculature of the nose is found beneath the dermis, and injections should be administered deep to the musculoaponeurotic layers. It is crucial not to inject superficially into the alar groove or nasal tip, as nasal injections are the primary cause of tissue necrosis and the second most common site leading to visual loss.

Pertinent Anatomy of the Nasal Area:

Muscles

Nasalis: Originates on the maxilla; Inserts on the nasal bone; The transverse portion compresses the nostrils; The alar portion dilates the nostrils.

Levator Labii Superioris Alaeque Nasi: Originates on the nasal bone; Inserts on the nostril and upper lip; Dilates the nostril and elevates the upper lip.

Depressor Septi Nasi: Originates on the maxilla; Inserts on the nasal septum; Depresses the nasal septum.

Blood Vessels

Vascular Danger Zones

The subdermal plexus is a prominent network of blood vessels in the nasal tip. The nasal skin has an extensive arterial and venous system that is situated directly above the nasal musculature (SMAS layer).

Injecting filler superficially in the nasal tip or alar groove can cause necrosis in the tip or alar area, respectively.

The vasculature of the dorsum tip and sidewalls of the nose connects with the ophthalmic artery. Any intravascular injections could result in retrograde migration of filler material, causing blindness or ischemia.

Lateral injections should be performed in a deep layer, 3 mm above the alar groove. Midline injections into the tip and dorsum should be deep in a pre-perichondral or pre-periosteal layer.

 

Emergency treatment

Patients can experience tissue necrosis days after receiving filler injections into the supra-tip and left tip/alar junction. Emergency treatment response can include multiple injections of hyaluronidase at 10-minute intervals to the nasal tip, alae, dorsum, and sidewalls.

Follow-up medication can consist of 81 mg ASA and topical Nitro paste to support increased blood flow to the areas. Hyperbaric chamber sessions are also recommended to increase oxygen perfusion into damaged areas. Commonly, 10-12 sessions are applied. Damage is directly related to the type of product and the volume injected into the targeted regions.

The Infraorbital Region

It is crucial to understand how to inject soft tissue fillers into the infraorbital area properly. Many patients notice hollowness in their lower eyelid, which corresponds with a tear trough deformity.

To seamlessly blend the lid and cheek junction, a technique will be demonstrated to safely improve the lower eyelid and cheek. Proper knowledge of the anatomy of the infraorbital nerve and artery is vital to avoid serious complications, such as blindness.

Here are some key points to keep in mind when using fillers in the tear trough and midface area.

1. Use low-G (low G prime) fillers and less hydrophilic fillers.
2. Hyaluronic acid fillers are preferred, as they can be reversed with hyaluronidase if needed.
3. Inject small amounts of filler in a low-pressure manner, always using a retrograde and antegrade technique.
4. Avoid direct, deep injections into the area around the infraorbital foramen.
5. The best practice is to inject inferiorly and laterally to the location of the foramen.
6. The primary injection sites for blending are along the zygomatic arch and the malar eminence.
7. Secondary injection sites are below the zygomatic arch, infra-malar region and the superficial fat compartments of the midface.
8. When injecting the tear trough, focus on the lateral two-thirds and stay in a deep (pre-periosteal) plane.
9. Inject a low volume of filler in a cross-hatching pattern.
10. Avoid direct injections overlying the infraorbital foramen; do not deposit filler near this area.
11. Filler deposited near the foramen may result in the migration of emboli in a retrograde fashion to the ophthalmic artery.
12. When injecting from the tear trough laterally, keep the needle in a deep pre-periosteal plane.
13. Injections near the infraorbital foramen should be avoided.

It is crucial always to practice safe injection techniques and to receive professional training before attempting any injections.

Regarding volumizing injections, the malar and zygomatic eminence can be filled laterally by performing depot injections in a deep plane.

The needle should be perpendicular to the skin surface to ensure proper injection technique. When injecting the tear trough from below, the needle should be directed laterally to the location of the infraorbital foramen.

Additionally, the needle should be in a deep pre-periosteal plane and can be fanned laterally to add more volume.

It is essential to avoid injecting near the infraorbital foramen to prevent potential complications.

Safety in the Infraorbital Area

When administering injections in the infraorbital area, it is essential to have a comprehensive understanding of the injection depth and the area’s anatomy to avoid damaging blood vessels. Cannulation of the infraorbital artery and filling injections can cause serious complications, such as blindness resulting from retrograde filler migration. Injuring the infraorbital nerve can cause sensory changes and pain.

Before administering injectable fillers, it is important to assess the malar area and tear trough to identify the best treatment site. The primary objective is to subtly enhance the region without overcompensating with excessive volume.

Pertinent Anatomy

The Orbicularis Oris muscle originates from the maxilla and mandible, and its function is to contract and pucker the lips. The Zygomaticus Major muscle, which helps elevate the upper lip and the corner of the mouth, originates from the zygomatic bone and inserts at the modiolus.

Meanwhile, the Zygomaticus Minor muscle, which elevates the upper lip, also starts from the zygoma and inserts into the upper lip.

Vessels

The infraorbital foramen is roughly one finger width below the infraorbital rim. You can identify the position by drawing a vertical line that extends from the medial limbus. When administering injections to the tear trough or malar eminence, it is crucial to be cautious of the infraorbital foramen’s location.

Intravascular injections into the infraorbital artery can migrate backwards and lead to blindness or ischemia. Applying pressure or causing injury to the infraorbital nerve may result in paresthesia and numbness.

Vascular Danger Zones

The infraorbital foramen is located within a vertical plane that aligns with the medial limbus. The location is approximately one fingerbreadth below the infraorbital rim.

When injecting the infraorbital region, it is essential to keep these anatomical measurements in mind.  Administer the injections laterally at the foramen, and approach any medial injections with caution.

If more filler is required, it can be applied more deeply and positioned towards the center. It is important to note that the Facial vein is located laterally to the foramen and is closer to the surface. Therefore, it is essential to avoid injecting into this vein by maintaining a deep position during injections.

Conclusion

Mastering the nasal and infraorbital regions is among the most challenging—and essential—skills in aesthetic medicine. These areas require not only technical precision but also a thorough, three-dimensional understanding of vascular anatomy to avoid serious complications such as necrosis or vision loss.

Safe and effective injections in these regions depend on respecting anatomical layers, selecting the correct injection plane, and consistently recognizing vascular landmarks like the angular, dorsal nasal, and infraorbital arteries.

Hyaluronic acid fillers, when used carefully and with the option for enzymatic reversal, remain the safest and most versatile agents for achieving controlled, reversible results. As practitioners improve their expertise, following anatomy-informed techniques, using minimal injection volumes, and continuing professional education become fundamental to both patient safety and aesthetic excellence.

Incorporating new anatomical insights and evidence-based safety protocols ensures every treatment reflects not only artistry but also scientific accuracy.

At the Myoguide Academy, our goal is to equip clinicians with the necessary anatomical knowledge and procedural confidence to deliver safe, predictable, and superior outcomes—because knowing where not to inject is just as important as knowing where to enhance.

 

One of the benefits of learning at the Myoguide Academy is the fully accessible 3D-rendered anatomical models. These models can be explored in both longitudinal and cross-sectional views, which support your 3D situational awareness—an essential part of the learning process.

Check out the quiz:

Which of the following fillers is best known for being reversible with hyaluronidase?

1. Calcium hydroxylapatite
2. Poly-L-lactic acid
3. Silicone
4. Hyaluronic acid
5. Polymethyl methacrylate (PMMA)

Why are blunt-tip cannulas often preferred over needles for deep cheek or midface filler placement?

1. Cannulas create a more rigid contour
2. Cannulas reduce the risk of intravascular injection
3. Cannulas deliver filler at a more superficial depth
4. Cannulas dissolve filler automatically over time
5. Cannulas stimulate more collagen

You are treating a patient with thin under-eye skin and visible tear trough hollowing. Which combination is most appropriate?

1. High G-prime filler with a sharp needle
2. Volumizing filler and fanning with a 27-G cannula
3. Low G-prime, less hydrophilic filler with a 25-G cannula
4. Medium G-prime filler with bolus technique
5. HA filler and superficial threading with a needle

A patient develops swelling and unevenness after a nasolabial filler treatment using a sharp needle. What’s the most likely contributing factor?

1. Using hyaluronic acid
2. Choosing a low G-prime filler
3. Injecting too superficially with a needle in a high-movement area
4. Using a cannula instead of a needle
5. Failure to massage after injection

A colleague is planning to treat the nose using a 27-G cannula and a highly hydrophilic filler. What is the best critique of this approach?

1. The technique is ideal for volume expansion
2. Cannulas are always safer than needles in the nose
3. Hydrophilic fillers increase the risk of delayed swelling in tight nasal planes
4. 27-G cannulas are too blunt for the nasal tip
5. This method is standard for widening the columella

Feel free to contact us for the answers!

References

• Isaac, J., Walker L., Ali, S., Whitaker, I.  An illustrated anatomical approach to reducing vascular risk during facial soft tissue filler administration – a review, JPRAS Open, Volume 36, 2023, Pages 27-45, ISSN 2352-5878, https://doi.org/10.1016/j.jpra.2022.09.006
• Ghannam, S., Sattler, S., Frank, K., Freytag, D. L., Webb, K. L., Devineni, A., & Cotofana, S. (2019). Treating the lips and their anatomical correlates with respect to vascular compromise. Facial Plastic Surgery, 35(02), 193-203.
• Chatrath, V., Banerjee, P. S., Goodman, G. J., & Rahman, E. (2019). Soft-tissue filler–associated blindness: a systematic review of case reports and case series. Plastic and Reconstructive Surgery Global Open, 7(4).
• Cotofana, S., & Lachman, N. (2019). Arteries of the face and their relevance for minimally invasive facial procedures: an anatomical review. Plastic and reconstructive surgery, 143(2), 416-426.
• Scheuer III, J. F., Sieber, D. A., Pezeshk, R. A., Gassman, A. A., Campbell, C. F., & Rohrich, R. J. (2017). Facial danger zones: techniques to maximize safety during soft-tissue filler injections. Plastic and reconstructive surgery, 139(5), 1103-1108.
• Liu, S., Yan, W., Wang, G., Zhao, R., Qiu, H., Cao, L., & Wang, H. (2021). Topographic anatomy of the zygomatico-orbital artery: Implications for improving the safety of temporal augmentation. Plastic and Reconstructive Surgery, 148(1), 19e-27e.
• Rohrich, Rod & Bartlett, Erica & Dayan, Erez. (2019). Practical Approach and Safety of Hyaluronic Acid Fillers. Plastic and Reconstructive Surgery – Global Open. 7. 1. 10.1097/GOX.0000000000002172.
• Allen, Shaun (2023). Anatomic danger zones for facial injection of soft tissue fillers- UpToDate. Retrieved from https://www.uptodate.com/contents/anatomic-danger-zones-for-facial-injection-of-soft-tissue-fillers#references