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ANATOMICAL STUDY
Anatomic Study of Ophthalmic Artery Embolism
Following Cosmetic Injection
Sufan Wu, MD, PhD, Lei Pan, MD, Hua Wu, MD, Hangyan Shi, MD, Ye Zhao, MD,
Yu Ji, MD, and Haifeng Zeng, PhD, MD
Introduction: Cosmetic injections of dermal fillers or fat could
cause ophthalmic artery embolism and even blindness, the high-risk
regions of which are considered glabellar, nasal dorsum, and
nasolabial fold. Understanding anatomy of the related arteries is
important for a physician to safely perform filler injections. To
investigate the mechanisms of ophthalmic artery embolism follow-
ing the injections, cadaver anatomy was studied.
Methods: Ophthalmic artery, facial artery, their branches, and
anastomoses among them were anatomized in 12 fresh cadavers.
Mimetic injections of hyaluronic acid were performed in glabellar
region, nasal dorsum, and nasolabial fold, the relationships between
injected filler and related arteries were then investigated.
Results: It was clearly found that 4 arteries were located in
common injection regions and connected to ophthalmic artery:
supratrochlear artery, supraorbital artery, dorsal nasal artery, and
angular artery. In the glabellar region, the deep injection on the
periosteum will be risky to injure supratrochlear artery and
supraorbital artery, whereas in nasal dorsum and nasolabial fold,
the sub- superficial musculo aponeurotic system layer injection has
the possibility to injure dorsal nasal artery, angular artery, and facial
artery.
Conclusion: The anatomic mechanism of ophthalmic artery
embolism is the anastomoses among the related arteries and
ophthalmic artery. Based on the findings of the study, injections
in periosteum layer at glabellar region or sub-superficial musculo
aponeurotic system layer of nasal dorsum and nasolabial fold are
not advised.
Key Words: Blindness, cosmetic injection, embolism, filler,
occlusion, ophthalmic artery
(J Craniofac Surg 2017;00: 00–00)
C osmetic injections of dermal fillers or fat are rapidly increasing
in recent years. ASPS data shows the filler injection procedures
in 2015 have increased 274% compared with that of 2000 and have
been a proportion of 15% in total cosmetic plastic procedures.
Regarding complications of the injections, the most serious is
From the Department of Plastic Surgery and Reconstructive Surgery,
Zhejiang Provincial People’s Hospital, Hangzhou, China.
Received December 27, 2016.
Accepted for publication January 8, 2017.
Address correspondence and reprint requests to Sufan Wu, MD, PhD,
Zhejiang Provincial People’s Hospital, Hangzhou, Zhejiang 310014,
China; E-mail: sufanwu@163.com
The authors report no conflicts of interest.
Copyright # 2017 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000003674
The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
ophthalmic artery (OA) embolism that may result in a series of
symptoms: skin necrosis, blepharoptosis, strabism, blurred vision,
visual loss, and even blindness (Fig. 1).
The outcomes of OA embolism are usually unacceptable,
especially when the central retinal artery (SRA) was involved.
Once blindness happened, it is almost incurable. In published
papers of blindness following the injections, there is no successful
rescued patient so far. The best strategy for the embolism is to take
precautions and master the knowledge of the anatomy and perform
the safe injections in the risky regions.
To well understand related anatomy and to safely perform filler
injections, OA, facial artery (FA), their branches, and anastomoses
among them were anatomized in 12 fresh cadavers. Mimetic
injections of colored hyaluronic acid (HA) were performed in
the glabellar region, nasal dorsum, and nasolabial fold, and the
relationships between injected fillers and related arteries
were investigated.
CADAVER ANATOMY
Anatomy of Arteries
Twelve fresh cadaver head specimens with red latex pouring of
artery (8 of them also with blue latex pouring of veins) were
included in the study. Ophthalmic arteries, facial arteries, their
branches, and anastomoses arteries among them were anatomized.
Attention was paid to the arteries that connected directly to
ophthalmic arteries. To investigate OA thoroughly, 6 eyeballs were
removed in 4 cadavers, in which all connection tissues were
dissected and only blood vessels and optic nerves were remained.
The appearances of anatomies were recorded using camera.
Mimetic Injections
In the glabellar region, nasal dorsum and nasolabial fold,
mimetic injections of colored HA were performed using sharp
needles and blunt cannulas. Injections were performed as clinical
usual operation: using 27G sharp needles with black HA in peri-
osteum layer, and using 25G blunt cannulas with blue HA in loose
layer under skin. The injected fillers were then exposed layer by
layer and the relationships between fillers and nearby arteries were
investigated carefully.
RESULTS
Appearances of Arteries
In 24 sides of 12 cadaver specimens, FA, OA, supratrochlear
artery (STA), supraorbital artery (SOA), and dorsal nasal artery
(DNA) had been found. In 6 sides of 4 eyeballs removed specimen,
it could be observed clearly that OA arose behind the eyeball and
branched into SOA, STA, DNA, and posterior ciliary artery.
The SRA was located in the center of the optic nerve (Fig. 2C).
The diameter of FA was similar to OA, around 2 mm, whereas the
diameters of STA, SOA, DNA, and AA were around 1 mm. It was
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Wu et al The Journal of Craniofacial Surgery
FIGURE 1. Several patients of ophthalmic artery embolism result from cosmetic
injections. (A) A 33-year-old women suffered from skin ischemia due to nose
dorsum injection of HA. (B) A 25-year-old women developed ptosis, strabism,
and skin ischemia due to the temple injection of autologous fat. (C) A 27-year-
old women suffered from skin ischemia and numbness due to temple injection
of HA. (D) A 30-year-old women underwent visual change, complete ptosis, and
skin ischemia due to nasal dorsum injection of HA. HA, hyaluronic acid.
clearly recognized that 3 main branches (STA, SOA, DNA) directly
originated from OA; moreover, AA originated from FA and directly
connected to OA.
In the glabellar region, SOA arose through supraorbital notch
(7 specimens) or supraorbital foramen (3 specimens), whereas STA
run medially to SOA, and both of them were located in the periosteum
layer. They ascend superiorly and perforated into frontal muscle at 1.5
to 2 cm above the supraorbital rim. Dorsal nasal arteries were
basically located at 2 sides of nasal dorsum. They run under the
superficial musculo aponeurotic system (SMAS) plane at the nasal
root, and gradually ascend superiorly from the nasal fascia plane to
the subcutaneous plane at the lower part of the nose (Fig. 2B). In all
specimens, FAs run just beneath the nasolabial fold from the corner of
the mouth to the nostril. They were basically located sub-SMAS
FIGURE 2. Anatomy of facial artery and ophthalmic artery. (A) Appearance of
facial artery (FA) and its branches including lateral nasal artery (LNA), and
branches of ophthalmic artery (OA), supratrochlear artery (STA), supraorbital
artery (SOA), and dorsal nasal artery (DNA). In this specimen, angular artery is
absent and there is no direct anastomosis between FA and OA. (B)
Heteromorphosis of DNA, in which 3 DNAs are found on nasal dorsum, 1 of
them was just located in the midline of nasal dorsum (arrow). (C) Exposure of
OA and its branches after removing of eyeball. Main branches of OA are
exposed, which included SOA, STA, DNA, and posterior ciliary artery (PCA). The
central retinal artery (SRA) was located in the center of the optic nerve.
2 #
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 00, Number 00, Month 2017
layer, under the levator labii superioris and levator labii superioris
alaeque nasi (Fig. 2A). whereas in 4 specimens, the FAs were located
in subcutaneous plane in nasolabial fold.
It was found that the depths and routes of the FA, OA, and their
branches vary. The AA only existed in 13 sides of 7 specimens. In
the specimens without AA, there was no direct anastomosis
between FA and OA (Fig. 2A). Heteromorphosis of DNA was also
found in 1 specimen, in which 3 DNAs were found on the nasal
dorsum. One of them was just located in the midline of nasal dorsum
(Fig. 2B).
Relationship Between Injected Fillers
and Arteries
There was a relatively regular pattern of the relationship
between injected filler and nearby arteries. In the forehead region,
fillers injected using blunt cannula were basically located beneath
the frontalis, where the SOA and STA were located. Fillers injected
deeply in the periosteum were located beneath the SOA and STA. In
the glabellar region, the black-colored fillers injected using sharp
need were located in the periosteum plane, which was the same
layer as the SOA and STA. The STA and SOA ascend superficially
in the upper forehead region (Fig. 3A). In the nasolabial region,
blue-colored fillers were injected into the loose plane under the
SMAS, which were the same plane as the FA and were very close to
it (Fig. 3B). In the nasal dorsum injection, black-colored fillers were
located in the periosteum plane, whereas the blue-colored fillers
were in the nasal dorsal fascia. In the nasal root region the injected
fillers were in the same plane as the DNAs and were very close to
them (Fig. 3C).
DISCUSSION
The main branches of OA are as follows: STA, SOA, DNA, SRA,
posterior ciliary artery, lacrimal artery, ethmoidal artery, palpebral
artery, and muscular artery. Facial artery sometimes has anasto-
mosis to OA through its terminal branch AA (Fig. 4). In the present
study, it was found that STA, SOA, and DNA directly connected to
FIGURE 3. Relationship between injected fillers and nearby arteries in forehead
and grabellar (A), nasolabial fold (B), and nasal dorsum (C). Filler injected in
periosteum plane in glabellar (3) was in the same plane as the STA (1), whereas
beneath the STA when injected in forehead region (4). An anastomosis (2)
between superficial temple artery and STA and a supraorbital vein (5) were
presented. Filler injected using blunt cannula in nasolabial region (7) was
exposed after dissection of Levator labii superioris muscle (8), which was mainly
located under SMAS plane and close to facial artery (6). In the nasal dorsum,
both deep injection using sharp needle (9) and middle layer injection using
blunt cannula (10) were performed. Black colored filler was located in the
periosteum, whereas the blue colored filler is in the nasal dorsal fascia and close
to DNAs (11). DNA, dorsal nasal artery; SMAS, superficial musculo aponeurotic
system; STA, supratrochlear artery.
2017 Mutaz B. Habal, MD
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The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017
FIGURE 4. Diagram of branches and anastomoses of ophthalmic artery and facial
artery, in three dimensional (A) and plane (B) graph. The main branches of
ophthalmic artery are supratrochlear artery (so), supraorbital artery (st), dorsal
nasal artery (dn), central retinal artery (cr), posteriorciliary artery (pc). Facial artery
(f) has main branches including lateral nasal artery (ln), superior labial artery (sl),
inferior labial artery and angular artery (a). Angular artery is the terminal branch of
the facial artery and connects with the ophthalmic artery directly. The major risk
regions of injection are glabellar, nasal dorsum, and nasolabial fold and forehead.
According to the locations of the arteries, subcutaneous injections in galbellar (1)
and nasolabial fold (3), or periosteal injection at the rim of apertura piriformis (5),
nasal root (2), and upper forehead (4) are advised.
the OA in all specimens, and AA was also anastomosis to it in 54%
(13/24) of specimen. This anatomic characteristic suggested that 4
arteries (STA, SOA, DNA, and AA) are the main risky vessels
involved in cosmetic injection. The anastomosis among the arteries
is the reason that injections in the risky arteries could result in
blindness. The 4 risky arteries distribute under facial skin and
directly connect to the OA, they may lead to occlusion when their
walls are broken by injection. The plane and route of the risk arteries
are individually different. Typically, STA and SOA are located in
the periosteum layer in the glabellar region, and ascend to the
SMAS layer in the upper forehead region.
It could be proposed that the routes and locations of the 4 risky
arteries are the dangerous injection regions of OA occlusion, which
are glabellar region (SOA, STA), nasal dorsum (DNA), and naso-
labial fold (AA) (Fig. 4B). Clinical findings have shown that the
major risky regions on the face are glabellar,1,2 nasal dorsum,3,4 and
nasolabial fold.1 It was reviewed that blindness was most often
associated with injection of the glabella (50%).5 In a 75 visual loss
patients review, glabella, nasal dorsum, and nasolabial fold were the
most frequent injected sites, with 45%, 25%, and 19% patients,
respectively. Moreover, 18 patients (24%) were diagnosed with
cerebral infarction.6 Forehead is also the risky region for artery
occlusion. Three patients of blindness caused by HA, autologous
fat, and Artefill injected into the forehead,7 and 2 patients of
hemiparesis and visual loss after autologous fat injection into the
forehead8,9 were reported. In another 98 patients review, the sites of
high risk for visual loss were the glabella (38.8%), nasal region
(25.5%), nasolabial fold (13.3%), and forehead (12.2%).10 The
oretically, the closer branch locates to OA, the more dangerous
to cause it occluded. Within 4 risk arteries, SOA is the closest to
OA, the glabellar is thus the most dangerous region of injection. On
the other hand, to perform the local treatment of artery occlusion,
the SOA is probably the first choice. It was reported that injection of
hyaluronidase into supraorbital notches surrounding SOA could
relieve visual symptoms and return eyesight.11 The vascular
anatomy is quite complex and has tremendous individual variations.
In our study, some arteries were found to have various routes and
even different planes. For example, dorsal nasal artery (DNA) could
present 3 vessels (Fig. 2B) and transverse anastomosis between
DNA, absence of AA (Fig. 2A), FA located above the SMAS. Due
# 2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Anatomy of Ophthalmic Artery Embolism
to the extensive anastomoses among the arteries on the faces, there
are actually no absolutely safe regions or routes for filler injections.
Even earlobe injection could cause blindness.12
All injectable fillers including autologous fat2,9 could result in
OA occlusion.. Hyaluronic acid is probably the most frequent
artificial material to cause visual loss due to its wide clinical
usage,13,14 and other materials such as hydroxylapatite15–17 were
reported as well. In a review of 75 patients of visual loss, the
percentages of autologous fat, HA, collagen, and corticosteroids
injection are 49%, 20%, 7%, 5%, respectively.6 In another review of
98 patients, autologous fat (47.9%) was the most common filler
type, followed by HA (23.5%).10 Regarding the prognosis of the
artery occlusion, the autologous fat injections were associated with
higher risk of cerebral infarction than that of HA.18,19 One possible
reason for it is that autologous fat is more prone to obstruct proximal
part of OA, whereas HA obstructs distal branches.20
Injection to risk regions such as nose, nasolabial fold, and
glabella requires extreme caution.5 It has been concluded that there
is actually no safe, feasible, and reliable treatment for OA embo-
lism, precaution to avoid this complication by appropriate operation
is thus the important procedures, which includes aspiration before
injections, using blunt cannulas, low pressure injection, least
amount per injection, limited volume per session, and no injection
into pretraumatized position.5,21,22 Besides these usual procedures,
there are also some special precautions for the risk regions based on
the findings of the present study. In the glabellar region, middle or
superficial injection is relatively safe for the reason that SOA and
SOT are located in the deep plane, whereas in the upper forehead
region, deep injection on the periosteum is advised as the SOA and
SOT ascend superficially to the frontalis in this area. It was
recommended that intradermal injection of the glabellar region
should be given superficially and medially.23 In nasal dorsum and
nasolabial fold, deep injection on the periosteum is safer than the
sub-SMAS plane.
CONCLUSION
The anatomic mechanism of OA embolism is the existence of
anastomoses among risk arteries and OA. The findings of the study
suggested that deep injections are safe in the face except in the
glabellar region; moreover, injections in periosteum plane at gla-
bellar or sub-SMAS plane at nasal dorsum and nasolabial fold are
not advised.
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4 # 2017 Mutaz B. Habal, MD

Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.