Can a cannula be inserted too high for dermal filler treatment? Diagnosed w/ nerve damage due to bad injection technique?(photo)

Got .5cc Juverderm Voluma 3 months ago. The injector inserted cannula in 1 area in each cheek. She really struggled to get product in & hurt my left cheek. The area inflammed, sore & discomfort for first 4 weeks then constant dull pain with intense stabbing pain & tingling, crawling feeling. Diagnosed with infraorbital nerve damage. My 2nd opinion Aesthetics Surgeon said the cannula looked like it was inserted too high? Could this be true? (Insertion point still visible in picture)

Doctor Answers 5

The infraorbital nerve below the eyes is quite resilient to injury, so permanent damage is unlikely in filler placement

Thank you for your question. I understand you had half a cc of Juvederm placed in the infraorbital cheek area three months ago, and in the first four weeks after the procedure, you experienced stabbing pain, swelling and inflammation in the area. You’re wondering if the cannula was placed too high, and after visiting a doctor to get a second opinion, you’ve come to the conclusion that there is some permanent infraorbital nerve damage.

Before we get into the details of what happened, let me just tell you a little bit about myself: I'm a Board-certified cosmetic surgeon, certified by the American Board of Cosmetic Surgery, and a Fellowship-trained oculofacial plastic and reconstructive surgeon. I specialize in Ophthalmology, or eye surgery, and I work extensively with the eyelids and the orbit lacrimal system. A significant part of my career has been focused on treating orbital disease, orbital tumors, and orbital trauma, so I can certainly speak from a lot of experience, and can give a little context of what you may have experienced, and what to anticipate.

First of all, I think the intention of your doctor was to avoid the challenges of using a needle, and to avoid causing any bleeding or puncturing of the anatomy in that area. To ensure this, they used a blunt tip cannula, which is designed to work its way around the tissue and other structures, so it doesn’t pierce through anything like a vessel. However, it is important to understand that even with a blunt tip cannula, it will still meet with some resistance. In this case, it seems that your doctor struggled with the placement, applied a lot of force, and then overshot, although I can’t say this definitively as I was not present during the procedure.

The under eye area is where the infraorbital nerve bundle, or neurovascular bundle, is located. Determining whether there is long-term damage to this area is difficult because the trauma seems to have caused some inflammation as well. In addition to this, trauma can take six months to a year to fully heal, so it can be difficult to determine the extent of the damage at this point in time.

It is important to understand that the infraorbital nerve can withstand a lot of trauma. To put it into context, this is an area t can get traumatized often in facial fractures and other blunt trauma injuries. This space is also routinely injected with local anaesthesia by dentists, to intentionally create numbness for procedures. I have also seen patients who have been shot, who have been hit with bats, who have been in terrible motor vehicle accidents and had profound issues with the infraorbital nerve, and in spite of that, it heals. It is common for this area to receive quite a bit of trauma and not have long-term injury. In your case, there could have been some localized bleeding, irritation, or swelling, but because it was a blunt instrument, it seems unlikely that any piercing of the nerve or permanent numbness has occurred.

In addition to this, 0.5 CCs of filler is not a lot, if you look at the scope of things. One of the strategies to consider is to dissolve the filler, and see if the pressure from the filler is what is causing some of these symptoms. This can be done with the help of hyaluronidase, which is an enzyme that can dissolve hyaluronic acid fillers such Restylane, Juvederm or Voluma, is areas where it is not wanted.

That being said, there is an art and a technique to the proper placement of fillers. In our practice, we do a procedure called the Y Lift®, wherein we augment the cheek areas, among others areas of the face, with a blunt tip cannula placed strategically in these areas. There are a lot of vessels and nerves in this submalar space, so it’s usually a matter of trying to get the material in the right place without causing any trauma to the patients.

Other options to consider are to visit an oculoplastic or orbital specialist to get a second opinion to make sense of what’s going on; having imaging studies, such as an MRI, done; or simply wait it out and allow it to resolve on its own. As I mentioned before, you can have the material dissolved and perhaps also get a recommendation for anti-inflammatory to help with the inflammation issues. At this point, it’s just a matter of getting the right information from the right source, and so you have the guidance you need.

I hope that was helpful and I wish you the best of luck!

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New York Oculoplastic Surgeon
4.3 out of 5 stars 62 reviews

Filler

It is possible that the filler was injected into the infraorbital nerve and that would cause multiple symptoms.
That is why the injector need to be a doctor who is familiar with the detailed fine anatomy of the face.
Now treatment is beyond a nurse or PA injector, It requires a neurologist and plastic surgeon to confirm the diagnosis of neuropraxia or neurotemesis. Plan a treatment plan. My guess with proper care this will resolve but will take a year.

Samir Shureih, MD
Baltimore Plastic Surgeon
4.2 out of 5 stars 7 reviews

Nerve Damage after Fillers

Where the cannula enters isn’t the root of the problems you've been facing. It is not the fault of how it has been inserted rather the technique after insertion that has caused the problem. With injury, many people will experience temporary numbness to the cheek and gums.  Usually, this resolves over weeks to months.  Make sure that your original injector is aware of your condition.

Hardik Soni, MD
Summit Emergency Medicine Physician
5.0 out of 5 stars 24 reviews

Nerve Damage after Fillers

Your photo seems to indicate the usual area for the infraorbital nerve.  What is the deficit that you are having?  With injury, many people will experience temporary numbness to the cheek and gums.  Usually, this resolves over weeks to months.  Make sure that your original injector is aware of your condition.  Wish you a speedy recovery!

Samuel Baharestani, MD
Long Island Oculoplastic Surgeon
4.8 out of 5 stars 24 reviews

Insertion point not relevant to your problem

Where the cannula enters doesn't cause the problems you've been having. It isn't too far off from where I insert. This is not the culprit. It is the technique after insertion that has caused the problem.

Steven F. Weiner, MD
Panama City Facial Plastic Surgeon
4.6 out of 5 stars 27 reviews

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