Why is filler in the glabella area so risky?

Question

I have a deep divot that has not been able to be fixed by Botox alone. I really need filler to help the area smooth out the divot. Seems like most people do not recommend getting filler there for the risk of blindness. But how often does that happen? Are there any other safer alternatives? Of safer fillers out there?

Anna Chacon, MD, FAAD · Answer

The concern is very real, even though blindness from filler is extremely rare. The glabella—the area between the eyebrows—is considered one of the higher-risk areas for filler because of its close connection to vessels that communicate with the ophthalmic artery, which supplies the eye. If filler is accidentally injected into one of these vessels, it can travel backward into the ophthalmic circulation and potentially block blood flow to the retina.

The reason physicians take this risk so seriously is that, although uncommon, the outcome can be devastating and may be permanent. Recent reviews of reported cases continue to identify the glabella among the higher-risk injection sites, although the nose and forehead are also major areas of concern.

How often does blindness happen?

Unfortunately, there isn't a reliable percentage that can be given for an individual injection. The complication is sufficiently rare that we don't have a good denominator—there are many millions of filler injections performed, while the medical literature consists primarily of reported cases.

So I would describe the risk as very low, but not zero, and importantly, it is not a complication that can be completely eliminated by choosing a particular filler or injection technique. The FDA specifically warns that inadvertent vascular injection of filler can cause tissue necrosis, stroke, or blindness.

Is there a "safer" filler for the glabella?

There isn't a filler that makes the glabella risk-free.

Interestingly, reported cases of vision loss have involved several different filler materials, including hyaluronic acid, fat, collagen, poly-L-lactic acid, and calcium hydroxylapatite. Hyaluronic acid has actually accounted for a large proportion of reported cases, likely in part because it is so commonly used.

One advantage of hyaluronic acid (HA) is that, unlike many other fillers, it can be treated with hyaluronidase if a vascular occlusion occurs. However, this should not be interpreted as meaning that HA filler is safe to inject into the glabella. Once an arterial occlusion affecting vision occurs, treatments have unfortunately not been shown to reliably restore vision.

What about your particular divot?

This is where I would be conservative. If Botox isn't correcting the depression, it suggests that there may be a structural component that Botox simply can't address. But that doesn't automatically mean that placing filler directly into the glabella is the best solution.

Depending on exactly where the divot is and what is causing it, alternatives might include very conservative treatment of the surrounding anatomy rather than directly filling the highest-risk portion of the glabella. In some situations, treating adjacent areas can soften the appearance of a depression without placing filler directly into the central glabella.

There are also patients for whom a small, carefully planned amount of filler may be considered by a highly experienced injector, but the decision has to be weighed against the fact that this is an elective cosmetic procedure with a very uncommon but potentially catastrophic complication.

I would also be particularly cautious about anyone suggesting that a cannula, a particular filler, or a particular injection technique makes blindness impossible. These techniques may be intended to reduce risk, but none eliminates the vascular anatomy or makes the complication impossible. Even a relatively small amount of filler can potentially obstruct a vessel.

If filler is ever placed in this region, it should be done by a physician who is very familiar with the vascular anatomy of the glabella and who has a clear emergency protocol for vascular occlusion. And if there is sudden vision change, unusual severe pain, skin blanching or discoloration, or neurologic symptoms during or shortly after filler injection, that is an emergency requiring immediate medical attention.

Overall, for a cosmetic divot in this particular location, I would consider the risk-benefit calculation carefully. There are ways to improve the appearance of the area, but I would not consider any filler "safe" in the glabella simply because it is a certain brand or type of filler.

Eric M. Joseph, MD · Answer

There are reported cases of blindness with HA fillers when they are used in the Glabella area. In our practice, we specialize in the use of microdroplet Silikon-1000, a permanent filler. With Silikon-1000, necrosis and blindness never occur since the size of a Silikon-1000 molecule is smaller than that of a red blood cell. Thank you for your question. Sincerely, Dr Joseph

Nelson Lee Novick, MD · Answer

Without a photo and a bit more history, I can only comment in the most general of terms. The concern for the use of filler in the glabella region is due to the richness of the vasculature in the region and its connection with retinal vessels. Subcision, which I have been performing routinely since 1995, works well for elevating and smoothing all kinds of indented scars and divets in all locations from all causes whether from acne, trauma, infections, surgery, etc.  What's more it has a several decades' long efficacy and safety record in all skin types. So, this may for you be the way to go.  That being said, when properly injected, and with an appropriate, injections of filler in this region (as well as in the forehead) can be safely administered. I not only routinely do so for my patients who require it, but have done so for myself and for my family members. This is not a region to be left to hands of an inexperienced injector accsustomed to using plain Juvederm or simple Restylane for treating ordinary smile lines. You would be wise to consult with a board certified, cosmetic dermatologist with extensive experience in both subcision and in filler use for the glabella.  Hope this helps and best of luck.

Camille Cash, MD · Answer

You are correct in your knowledge that administering fillers in the glabella is risky as it can lead to blindness.  A few other options to consider to address a divot include microneedling with Skin Pen, Morpheus8 which combines microneedling with RF technology, and laser treatments.  I've included a video on Morpheus8 that I hope you find helpful.

Glenn Murray, MBBS · Answer

Hello,

Glabella dermal filler is considered particularly risky due to its complex vascular anatomy. This region is rich in blood vessels that connect directly to the ophthalmic artery, which supplies blood to the eyes and surrounding structures. Inadvertent injection into these vessels can lead to severe complications, including blindness.
The glabella contains the supratrochlear and supraorbital arteries, which are branches of the ophthalmic artery. These arteries have limited collateral circulation, meaning that if they become obstructed, there is little alternative blood flow to compensate.

It is very important to choose an experienced practitioner for this treatment.

Darren West, MD · Answer

The glabellar area is risky for filler injection due to the proximity of vascular structures and the increased risk of vascular occlusion. Fortunately, the actual occurrence of vascular occlusion is rare. However, even a low risk of such a catastrophic complication makes it such that this in not considered a safe area for injection of filler. A couple of options to try would be smooth PDO threads or PRP/PRF. These can be used individually or together and work well with Botox.

Why is filler in the glabella area so risky?

Answers (6)

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