Cosmetic Fillers in the Face - Why Nerve Damage is Highly Unlikely

Author: Amiya Prasad, M.D.

Thank you for your question. It’s been about 3 months since you had half a CC of Juvederm placed in the infraorbital cheek area, and you're asking can a cannula be placed too high. Based on a series of descriptions you stated, it was in the first four weeks you had stabbing pain, and swelling and inflammation, and you also went for a second opinion and the doctor said you have some infraorbital nerve damage.

Your conclusion at this point is that there was infraorbital nerve damage that’s permanent. I think that we should kind of dissect out the details of the situation to understand more about what may or may not have happened, and what to anticipate. You also submitted a photo showing where the entry point was. So just to give you a little bit about my background, I'm a Board-certified cosmetic surgeon, certified by the American Board of Cosmetic Surgery. I'm also a Fellowship-trained oculofacial plastic and reconstructive surgeon. The specialty of Ophthalmology, or eye surgery, where we work extensively with the eyelids and the orbit lacrimal system. A significant part of my career has been in treating orbital disease, orbital tumors, and orbital trauma.

So I can speak from a lot of experience and also give you a little context of what you may have experienced and what to anticipate. So just looking at the area that the cannula was placed, I think of course that the intention of your doctor was to avoid the challenges met with using a needle, which could cause bleeding or puncture of parts of the anatomy in that area. To avoid that they used a cannula, or a blunt tip cannula. A blunt tip, in terms of concept, is meant to work its way through tissue, in a way where it does not pierce a vessel, and the structures basically just roll around, that's the concept.

Now, it's still important to understand tissue planes, because just because you have a blunt tip cannula doesn't mean—you also will meet a lot of resistance. It sounds like what you're describing your doctor was struggling, it might have been that your doctor was trying to get to a particular point, may have applied a lot of force and then overshot. Again, not being there, not knowing the details, I can't say that definitively. Nonetheless, there is a particular area under the eye where there is the infraorbital nerve bundle, or neurovascular bundle comes out. And this is an area where the nerves that go to the cheek to the left to the under eye area, the infraorbital nerve or the second division of the trigeminal nerve.

Cosmetic Fillers in the Face - Why Nerve Damage is Highly Unlikely

Now to determine if there is long term damage, is a little bit difficult because the trauma may have caused some inflammation which is what seems to be described. However, trauma can often take six months to a year to fully resolve. To give you a little bit of context and how this all fits in, is that the infraorbital nerve is very often traumatized in facial fractures, in various blunt trauma injuries, it is commonly injected with local anesthesia, the space around the infraorbital nerve or at times at the infraorbital canal or in that space, with a needle, and is routinely performed by dentists regularly to create numbness of the teeth, intentionally. So sharp instruments, it's not uncommon, or sharp needles are placed in this area and long term problems tends not to occur. So I think that there's no question that there was some trauma, and it could have been localized bleeding, or localized irritation and swelling that is responsible for what you've experienced, but since it was a blunt instrument, it seems unlikely any piercing of the nerve or long term permanent numbness is likely. And the volume of filler .5 CCs, which is in the scope of things, not a lot.

I think that one of the strategies that might be entertained is to actually dissolve the filler to see if maybe the pressure from the filler could also be responsible for some of these symptoms. So that's something to consider. Hyaluronidase is basically an enzyme that we often used to help patients who have come to us and consultation because they have hyaluronic acid filler, whether it’s Restylane or Juvederm or Voluma, in a place where they don't want it. And we are able to dissolve it. That being said, there is a lot of technique to placement of fillers.

We actually do the procedure called the Y Lift®, which is to augment the cheek area and we actually don't place the cannula, we do use blunt cannulas, but we place it in a strategic way to avoid those particular sensitive areas. But that doesn't mean I don't do injectables in this area, I do place filler in this area right near the space. In that little area of the cheek or the submalar space, there are lots of nerves and lots of vessels and it's just a matter of method to try to get the material in the right place and try to get it so that patients don't have these types of experiences. None the less I think you may want additional opinions maybe from an oculoplastic or orbital specialist. You may want to get some imaging studies such as an MRI to look at this area, or you may just want to wait it out and it might just resolve on its own. So although you went to an aesthetic doctor, you may want to go to a specialist as I described, an orbital specialist, just try to make sense out of what's going on and then take it from there. Like I said there are options to maybe dissolve the material, you may need some anti inflammatory, it might be able to mitigate some of the ongoing inflammation issues if you are still having the symptoms comparable to what you had initially. Since nobody except your doctor and you were there at the time of the procedure, it's hard to really predict or to describe exactly what could have happened at the time of the procedure.

But it's important to understand that the neurovascular bundle, the infraorbital nerve, it can take a lot of trauma. I have seen patients who have been shot, who have been hit with bats, who have been in terrible motor vehicle accidents, who had profound issues with the infraorbital nerve and it heals. So it just means that it can be tough and even when it is an operative procedure such as orbital decompression, the nerve can take a lot and still be fine. So now it's just a matter of getting the right information from the right source and the guidance that you need. So I hope it was helpful and I wish you the best of luck. Thank you for your question.

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