The Six Deep Danger Points of the Face: A Guide for the Wise Injector
Every part of the face has a reason to be injected. From the earlobe to the forehead, there is almost always some aesthetic indication for adding volume. But the art of injection is a continuous negotiation between what we wish to achieve and where we can safely place a needle. There are places where the anatomy itself demands our deepest respect, and where the risk of a catastrophic complication—like blindness or tissue necrosis—is real. Let us walk through these six deep danger points, not to frighten, but to arm you with the knowledge that makes you a safer, more confident practitioner.
The Forehead: The Supraorbital and Supratrochlear Arteries
We begin at the top of the face. The forehead is supplied by two critical arteries: the supratrochlear and the supraorbital. These are branches of the ophthalmic artery, which connects directly to the blood supply of the retina. That is what makes them uniquely dangerous. The good news is that you can often feel them. The bony notch where the supratrochlear emerges medially, and the foramen of the supraorbital laterally—these are palpable landmarks. In a slim or nervous patient, you may even feel a pulse.
The absolute prohibition is deep injection onto the periosteum around the orbital rim. That is the fastest way to send filler into the orbital blood supply. But if you understand the anatomy, you can chip away at the risk. How? First, always point your needle away from the orbit, so that the filler flows in the opposite direction. Second, you can compress the vessel with a finger while injecting—squash that artery so that filler cannot travel back toward the eye. Third, inject superficially, well above the periosteum. Fourth, aspirate, especially with low-viscosity products where aspiration works reliably. Fifth, use a cannula for larger volume work, like augmenting the entire forehead or creating a heavier brow ridge. And sixth, use small volumes at a time.
There is a school of thought that says the risk of blindness is so high that you should never inject the glabella. But the total risk remains one in a million. With good technique, hundreds of such injections can be performed without a single occlusion. The key is to justify the risk: if a patient has a deep frown line that affects their communication, there is often a strong reason to proceed. But always remember: you are in charge of your own risk. If you are uncomfortable, do not do it. No one should push you beyond your comfort zone.
The Midface: The Infraorbital Foramen
Moving down the face, we encounter the infraorbital foramen. This lies just medial to the mid-pupillary line. You can mark it by drawing a vertical line down from the center of the pupil. Everything medial to that line is a little riskier. The infraorbital artery is a branch of the maxillary artery, and if you occlude it, you can block blood supply to much of the midface, including the palate and the nasopharynx. A nasty place to get an occlusion.
The best way to stay safe is to mark the area and then simply not go near it. There is rarely a need to inject directly into that foramen. If you absolutely must add volume there—and some faces do require it—use a cannula and stay superficial. The foramen is a deep bony indentation. If you remain above it, in the fat pad, you are relatively safe. Many occlusions of the infraorbital artery have occurred when injecting the nasolabial fold with a needle angled slightly upward. So for that entire region, a cannula is your friend.
The Chin: The Mental Foramen
On the chin, we find the mental foramen. It is slightly smaller than the infraorbital, but equally important. A small vessel emerges here, and it is a branch of the inferior alveolar artery. This means it supplies blood to the teeth, the floor of the mouth, and the skin of the chin. An occlusion here could affect the entire lower third of the jaw. You might see superficial skin necrosis, but if the filler flows back, it could affect much deeper structures—even the tongue in theory, though that is extraordinarily rare.
The main indication for treating this area is chin volumization or projection. When you are adding volume to the chin, you may inject over the mental foramen to replace the fat pad. The foramen is about one centimeter lateral to the marionette line. To avoid it, palpate and feel for the bony indentation. Use small amounts of filler at a time. A cannula is much safer for this area, as it reduces trauma. And again, do not inject deep onto the periosteum in that exact spot. If you go too deep, you might hit the nerve, but rely on anatomy, not on patient reaction.
The Jawline: The Facial Artery at the Mandibular Groove
Moving laterally, we come to the entry point of the facial artery into the face. This is located at the little mandibular groove, just anterior to the masseter muscle. Many people can feel a pulse there, especially after exercise or if they are slim. It is a very dangerous place to put a needle. We often inject on the periosteum a few centimeters lateral to this point, at the gonial angle, which is safe. But as you move downward along the mandible, you approach the artery.
The worst technique is to do a large bolus along the jawline without palpating. To avoid this, always palpate the bone. Ask your patient to bite down to feel the masseter. The artery lies just anterior to that muscle. Never put a needle at that depth and at that point. If you need to add volume to the lower mandible, use a wide-bore cannula—one that is too large to easily penetrate a vessel. Gently nudge your way through the soft tissue, staying above the bone, and add the volume carefully.
The Temple: The Deep Temporal Vessels
Finally, we reach the temple. Here we have two deep temporal arteries that run on the periosteum and behind the zygoma, supplying the temporalis muscle. These are different from the superficial temporal artery. The danger is that when you revolumize the temple, you are often taught to inject onto the periosteum—a deep bolus. But there have been cases of blindness from temple injections. How? The deep temporal vessels are connected to the maxillary artery, which supplies most of the midface. Occluding them can cause a catastrophic blockage.
The more common route to blindness, however, is through the superficial temporal artery, which has anastomoses with the supratrochlear artery. Low-viscosity filler can flow through these connections and reach the eye. So when you inject the temple, you must be highly cautious. The old "bullet hole" technique of a large deep bolus is risky. Instead, many injectors now use the "Swift point"—a location more superior and medial, named after Arthur Swift, where you can place filler more safely, away from the deep temporal vessels. Always inject small volumes, aspirate, and consider using a cannula if you are going deep.
The Guiding Principle
Every occlusion risk must be weighed in terms of frequency and severity. Something that is infrequent but very severe—like blindness—is what we worry about most. The key is to layer multiple safety techniques: know your anatomy, palpate landmarks, use superficial injections, employ cannulas, aspirate when possible, and inject small volumes. No single technique guarantees 100% safety, but together they allow you to chip away at the risk, bringing it as low as possible.
So as you proceed in your practice, remember that every part of the face has a reason to be treated, but not every part should be treated the same way. Respect the anatomy, and let your knowledge guide your hand.