pISSN 2733-4813 • eISSN 2733-631X

Original Article
Aesthet 2020;1(1):1-7
https://doi.org/10.46738/Aesthetics.2020.1.1.1

ABCs in the Prevention of Filler-induced Ocular Complications

Won Lee, MD, PhD1 Background and Objectives

Hyoung-Jin Moon, MD2 Ocular complications are rare, but tragic, side effects of treatments with
Min-Ho Lee, MD3 hyaluronic acid filler. While several study groups have proposed preventive
guidelines for hyaluronic acid filler injections, their basis remains somewhat
Min-Sueng Kim, MD4
controversial due to a lack of science evidence thereon. The present study
Wook Oh, MD5 sought to simplify preventive guidelines for the use of hyaluronic acid filler
injections in clinical practice and to provide scientific data in support there-
1
Yonsei E1 Plastic Surgery Clinic, Anyang, Korea of.
2
Beup Aesthetic Plastic Surgery Clinic, Seoul, Korea
3
Bestop Clinic, Suwon, Korea Materials and Methods
4
Inee Clinic, Seoul, Korea We reviewed evidence of ocular complications secondary to filler injections
reported in the literature and recent publications on methods to prevent
5
Samsung Feel Clinic, Seoul, Korea
them.
Results
For easier memorization and recall during routine clinical practice, we
developed a set of guidelines organized as an acrostic list of ABCs. The
guidelines cover the following aspects of filler injections: An) anatomy (dop-
pler ultrasound), As) aspiration with proper technique, B) big cannulas, C)
compression, D) direction of injection, E) epinephrine, F) filler technique for
augmentation or wrinkle correction, G) gentle injection of a small amount,
and H) history of prior operations or injections.
Conclusion
Clinicians ought to consider the ABCs of hyaluronic acid filler injections for
the prevention of ocular complications.

Key words
Hyaluronic acid filler, Blindness, Prevention, Filler complications, Soft tissue
filler

Received April 1, 2020

Revised April 7, 2020
Accepted April 14, 2020

Correspondence
Won Lee
Yonsei E1 Plastic Surgery Clinic, Anyang
14072, Korea
E-mail: e1clinic@daum.net
https://orcid.org/0000-0001-7411-0198

C Korean Society for Laser, Dermatology and Trichology

CC This is an open access article distributed under

the terms of the Creative Commons Attribution Non-

Commercial License (http://creativecommons.org/
licenses/by-nc/4.0) which permits unrestricted non-
commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.

www.theaesthetics.org 1
INTRODUCTION
Hyaluronic acid (HA) filler injections are commonly
utilized in aesthetic procedures for facial rejuvenation.
However, the use of HA fillers is associated with serious
complications, including skin necrosis and blindness [1].
Although research has elucidated the potential pathophysi-
ologic mechanisms of ocular complications stemming from
the use of HA fillers and although several guidelines have
been proposed to prevent the occurrence thereof, stud-
ies have yet to provide scientific evidence in support of a
single treatment modality with HA filler that completely
or markedly reduces the likelihood of ocular complications
occurring, and since there is no definite treatment for cor-
recting HA filler-induced complications of the ocular area,
prevention is of utmost importance [2,3]. Accordingly, vari-
ous methods and guidelines aimed at preventing unwanted
complications from HA filler injections have been proposed,
although some are based only on consensus and have no
basis in scientific evidence [4,5]. Therefore, we sought to
develop clear guidelines based on recent scientific data
reported in the literature that are memorable and readily
applicable in clinical practice.
MATERIALS AND METHODS
To begin, we reviewed evidence on methods of preven-
tion of ocular complications secondary to filler injections
reported in the literature. The search terms ‘hyaluronic acid
filler’, ‘dermal filler’, ‘filler complications’, ‘blindness’, ‘ocular
complications’, and ‘vision loss’ were input as key words in
the search engines PubMed MEDLINE and Google Scholar.
A total of 34 articles addressing filler injections were re-
viewed. Finally, we developed a set of preventive guidelines
for HA filler treatment supported by recent scientific data.
RESULTS AND DISCUSSION
The guidelines that we propose are discussed in individ-
ual sections below. We have organized them as an acrostic
Table 1. ABCs in the prevention of filler-induced ocular complications
An) Anatomy (Doppler ultrasound)
As) Aspiration with proper technique
B) Big cannulas
C) Compression
D) Direction of injection
E) Epinephrine
F) Filler technique for augmentation or wrinkle correction
G) Gentle injection of a small amount
H) History of prior operations or injections
2 www.theaesthetics.org
list of ABCs for easier memorization and recall during rou-
tine clinical practice, as shown in Table 1.
An) Anatomy
All of the articles that we reviewed emphasized the im-
portance of awareness of anatomical structures during filler
injection procedures. As stated above, the pathophysiology
of filler-induced ocular complications is well known, and
the most important structures affecting ocular complica-
tions are the branches of the internal carotid arteries (Fig.
1). In the literature, several articles have analyzed ocular
complications associated with filler procedures, and while
some reported possible ocular complications as a result of
external carotid artery embolism, the rates thereof were
much less than those occurring as a result of embolism of
the internal carotid artery [6].
Unlike surgery, filler injection procedures are conducted
blindly (i.e., not under direct visualization of underlying
structures). Accordingly, no matter how well-versed the
clinician is in the vasculature of the internal carotid arteries,
filler injections are not 100% safe because of arterial varia-
tions. Indeed, several variations in the supratrochlear, supra-
orbital, and dorsal nasal arteries have been described [7,8].
In addition to variations, studies of the human anatomy are
primarily conducted in cadavers, the results of which may
differ from those in a living human body. Since we perform
procedures on the living human body, the actual anatomy
thereof is most important. Therefore, anatomical results
Supraorbital A.
Supratrochlear A.
Dorsal nasal A.
Internal carotid A.
External carotid A.
Fig. 1. Arteries of the face associated with ocular complications.
Red, internal carotid artery branches; Black, external carotid artery
branches.

reflected in imaging studies of live human subjects, such as
ultrasound, are essential to preventing vascular complica-
tions. Accordingly, clinicians have recently sought to imple-
ment the use of Doppler ultrasound to facilitate visualiza-
tion of the underlying vasculature in order to improve the
safety of HA filler procedures [9,10]: The detection of the
supratrochlear artery is particularly important in the correc-
tion of glabellar frown lines, and the artery exhibits several
variations that run in superficial or deep directions (Fig. 2).
The supraorbital artery shows anastomosis to the frontal
branch of the superficial temporal artery that is visible
under Doppler ultrasound [11]. The dorsal nasal artery is
important in augmentation of the nose with filler injections,
and it also has many variations detectible with Doppler ul-
trasound (Fig. 3) [12]. The use of Doppler ultrasound allows
the clinician to observe and avoid these pathways to inject
HA filler at the desired location without incurring injury
thereto.
As) Aspiration with proper technique
Aspiration of the needle prior to injection of HA filler
has been suggested to prevent vascular embolism [13],
Fig. 2. Doppler ultrasound for detection of the supratrochlear artery. The probe is positioned along the path of the supratrochlear artery (left), al-
lowing for the detection of the supratrochlear artery deep in the subcutaneous layer (right).
Fig. 3. Doppler ultrasound for detection of the dorsal nasal artery. The probe is positioned along the midline of the nose (left), allowing for the de-
tection of the dorsal nasal artery in the subcutaneous layer (right).
Filler Complication Prevention
Won Lee, et al.
Original Article
although many have deemed this ineffective [14]. We sus-
pect that the effectiveness of aspiration may depend on the
technique applied. HA filler injections can be performed
via either a linear retrograde technique or a bolus injection
technique. When applying a linear retrograde technique,
the clinician will continually move the needle tip, making
aspiration ineffective. With a bolus injection technique,
however, the needle tip does not move, and thus, aspira-
tion may be useful to prevent vascular embolism [15].
Nonetheless, aspiration tests can produce false negatives,
wherein, even though the needle tip is located inside a ves-
sel, blood is not detectable during aspiration. While this is
thought to be affected by filler rheology, needle diameter,
aspiration time, and negative pressure [16,17], aspiration
tests with filler appear to be more dependent of conditions
inside the needle. Accordingly, we have performed in vivo
tests with rabbits and found that all aspiration tests with HA
filler were positive when the needle was first primed with
normal saline (Fig. 4).
B) Big cannulas
Previous articles have recommended the use of small-
Aesthet Vol. 1 No. 1 April 2020 3
bore needles for filler injection [4,13,18]. However, while
the use a small-bore needle would minimize the likelihood
of perforating an artery, when the needle tip is placed in-
side the artery, embolism can still occur. Moreover, the use
of a small-bore needle poses a greater risk of the needle tip
being placed inside the vessel lumen. Compared to needles,
cannulas are thought to be less traumatic, although small-
bore cannulas (e.g., 27 G) appear to be as equally as dan-
gerous [19]: a recent article also demonstrated that a 27 G
cannula required similar forces as a 27 G needle for intraar-
terial penetration and that small-bore needles or cannulas
could penetrate an artery at less force than larger-bore ones
[20]. Therefore, we recommend the use of relatively larger
bore cannulas.
In regards to preventing arterial embolism, the outer di-
ameter of the cannula or needle is extremely important (See
Table 2 for needle diameters). When using a 30 G needle, its
outer diameter is 0.31 mm. Since important arteries, such
as the supratrochlear, supraorbital, and dorsal nasal arter-
ies, are about 1 mm in diameter [21], a 30 G needle tip can
be placed inside these arteries: theoretically, a 21 G needle
with an outer diameter of 0.82 mm could also be located
inside vessel. A schematic diagram is provided in Fig. 5.
C) Compression
During HA filler injection, compressing the pathway of
neighboring arteries is recommended, particularly along
the inferior medial orbital rim and the side of the nose
[22]. When performing forehead augmentation or glabellar
wrinkle correction, digital compression of the supratroch-
lear/supraorbital arterial pathway is required. For augmen-
tation of the nose, compression of the dorsal nasal artery is
needed. When digital compression is performed, however,
arterial flow by Doppler ultrasound cannot be detected [23].
Nevertheless, applying digital compression can help prevent
ocular complications should arterial embolism occur, as, in
a pathophysiologic context, ocular complications are known
to develop as a result of retrograde HA filler emboli to the
ophthalmic artery [2].
D) Direction of injection
Previous research has demonstrated that even cannulas
can perforate the arterial wall, and a perpendicular angle
between the artery and the cannula was one factor elicit-
ing vascular injury [19]. While more parallel cannulation is
known to be relatively safe, clinicians must also consider
the direction in which HA filler is injected after cannulation.
Since HA filler embolism occurs as filler enters the arterial
lumen via a perforation and completely fills the arterial lu-
men as the injection continues, injecting filler away from
the eye, rather than towards the eye, is paramount to pre-
venting ocular complications (Fig. 6).

30 G 0.31 mm
Fig. 4. Aspiration performed in rabbit femoral arteries. After priming
the needle lumen with normal saline, immediate blood aspiration is Artery
1 mm
noticeable.

Table 2. Needle diameters

23 G 0.64 mm
Outer diameter (mm) Inner diameter (mm)
Artery
18 G 1.27 0.84
19.5 G 0.99 0.69
21 G 0.82 0.51
22 G 0.71 0.41
23 G 0.64 0.34 20 G 0.91 mm
25 G 0.51 0.26 Artery
27 G 0.41 0.21
29 G 0.34 0.18 Fig. 5. Arterial diameter compared to cannula diameter. Use of a
small-bore cannula increases the risk of perforating the arterial lu-
30 G 0.31 0.16 men.

4 www.theaesthetics.org

E) Epinephrine
Previous articles have proposed the use of a small
amount epinephrine prior to HA filler injection [4,24].
The use of a small amount of epinephrine with lidocaine
limits any pain and bruising experienced by the patient.
Importantly, only a small amount of epinephrine is recom-
mended, as large amounts can hinder achieving the desired
appearance of the face.
F) Filler technique for augmentation or wrinkle
correction
In the correction of wrinkles, previous articles have
primarily recommended techniques that encompass con-
tinual movement of the needle tip when injecting HA filler
to prevent arterial embolism, both for an anterograde or
retrograde approach [4,18,24,25]. This, however, limits the
amount of filler that can be injected to only small amounts.
Meanwhile, in Asian patients, filler is also used for augmen-
tation of the nose, typically requiring injections of more
than 0.5 mL of hyaluronic acid filler, much greater than the
small amounts used for wrinkle correction [26]. For this
reason, a single bolus injection of HA filler to the supraperi-
osteal layer is considered safer for nose augmentation [27],
although clinicians ought to consider the properties of the
filler when doing so: HA filler has various rheological prop-
erties, and for nose augmentation at the supraperiosteal
layer, the HA filler should have a relatively high G’ [28]. Also,
when injecting a filler with a high G’, a large-bore cannula
should be utilized to limit the possibility of alterations to the
filler’s properties [29].
Fig. 6. Injections should be made in a distal direction away from the
eye.
Filler Complication Prevention
Won Lee, et al.
Original Article
G) Gentle injection of a small amount
Gentle injection is important to the behavior of the filler
upon injection. The force needed to inject filler is called the
injection force (Fig. 7). However, the actual force generated
upon ejection of the filler from the needle warrants addi-
tional consideration. This force is affected by the viscosity
of the HA filler and the inner diameter of the needle [30].
When the filler is ejected gently, the pressure generated by
the ejected filler is quite small, but when injected at only a
slightly higher force, this pressure increases greatly. In our
recent experiments (unpublished data), we noted that only
a small increase in ejection force can elicit a much higher
pressure (572.67 mmHg) beyond that of the normal systolic
pressure of blood vessels. In addition, gentle injection of as
little of filler as possible is also critical. A previous report de-
scribed the mean volume of the supratrochlear artery to be
approximately 0.085 mL [31]. Thus, injecting more than this
amount during one injection could allow the filler to reach
the ophthalmic artery and cause blindness (Fig. 8).
H) History
Previous surgical history can alter arterial pathways, so
much so that a few clinicians have recommended never
treating a previously traumatized area with filler injections
[32]. Alterations in the anatomical locations of vessels fol-
lowing surgical interventions, such as rhinoplasty, pose
several concerns [33]: For instance, in augmentation of the
nose, clinicians recommend injecting HA filler at the su-
praperiosteal layer, as it is well known that the dorsal nasal
artery is located in the subcutaneous layer at the nose [34].
However, in many Asian patients, augmentation rhinoplasty
is performed with silicone implants, and in such cases,
HA filler cannot be injected at the supraperiosteal layer
and should be injected more superficial than the implant,
40
(N, newton)
30
20
10
0
0 4 8 12 16 20
(mm)
Fig. 7. Injection force of hyaluronic acid filler. An average injection
force of 9.6 N was estimated.
Aesthet Vol. 1 No. 1 April 2020 5

Fig. 8. Pathophysiology of ocular complications from hyaluronic acid
filler. Hyaluronic acid filler elicits ocular complications as a filling com-
ponent inside the artery that moves towards the eye, not as individual
emboli. Thus, gentle injection with as little of filler as possible is rec-
ommended.
meaning it should be injected at the subcutaneous layer
where the dorsal nasal artery might located, thereby posing
a greater risk of vascular complications.
CONCLUSION
In the present study, we sought to provide simplified,
preventive guidelines supported by the literature for reduc-
ing ocular complications after procedures involving filler
injections. Clinicians ought to consider the ABCs of HA filler
injections for the prevention of ocular complications: An)
anatomy (doppler ultrasound), As) aspiration with proper
technique, B) big cannulas, C) compression, D) direction of
injection, E) epinephrine, F) filler technique for augmenta-
tion or wrinkle correction, G) gentle injection of a small
amount, and H) history of prior operations or injections.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article
was reported.
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