Purpose — To provide a defensible, anatomy-led protocol for safe injection across high-risk facial zones, aligned with Australian and international standards of clinical governance and patient safety. This policy integrates AHPRA cosmetic practice guidelines, NSQHS Clinical Governance standards, and global frameworks for injection safety and complication management. ^{1 2 3 4}

1. Forehead

Anatomical Overview

The forehead is primarily formed by the frontalis muscle overlying the frontal bone. The supratrochlear and supraorbital arteries and nerves emerge from the orbit and ascend vertically, connecting to the ophthalmic system. These anastomoses create potential retrograde embolisation pathways if filler is inadvertently injected intravascularly. ^{4 5}

Technique

Botulinum toxin should be placed intramuscularly in the frontalis in conservative, evenly spaced aliquots to prevent brow ptosis. Filler use is discouraged; if performed for contour smoothing, inject minute, superficial aliquots with strict aspiration and low pressure while avoiding peri-orbital zones. ^{1 6 7}

Risk Indicators

Blanching, severe pain, visual changes, or livedo require immediate cessation, aspiration (if feasible), warming, massage, and escalation via vascular occlusion and ophthalmic emergency pathways. ^{2 7 8 9}

2. Glabella

Anatomical Overview

The supratrochlear and supraorbital arteries traverse the corrugator and procerus muscles, presenting one of the most dangerous vascular regions for filler injection. ^{4 7}

Technique

Botulinum toxin may be injected directly into corrugator and procerus with caution to avoid diffusion medially. Dermal filler is strongly discouraged; if absolutely required, inject with a blunt cannula in a deep supraperiosteal plane using micro-aliquots and slow, low-pressure delivery. ^{1 2 7}

Risk Indicators & Response

Any blanching, pain, or visual symptoms mandate immediate activation of the vascular occlusion protocol and ophthalmology referral. Maintain full procedural documentation (product, lot, planes, actions) for defensibility. ^{2 5 10}

3. Temple

Anatomical Overview

The superficial temporal artery (STA) and its frontal branch run within or above the superficial temporal fascia. Deep temporal arteries lie between the temporalis and its deep fascia, requiring awareness of variable compartmental anatomy. ^{11 12}

Technique

Inject in a deep supraperiosteal plane via a posterior hairline entry using a 22–25G cannula. Deliver small boluses (0.05–0.2 mL) under low pressure, aspirating frequently. Avoid the mid-depth zone where the STA lies most vulnerable. ^{2 8 9}

Complications

Intravascular injection can cause scalp or brow ischaemia; compression and escalation per vascular occlusion SOP are essential. Haematoma from sentinel vein injury is possible; apply cold and document findings. ^{2 5}

4. Midface

Anatomical Overview

The infraorbital artery and nerve exit at the infraorbital foramen, while the angular artery courses medially toward the tear trough with extensive ophthalmic connections. Fat pad integrity determines contour and filler distribution. ^{13 14}

Technique

Inject high-G′ fillers on bone at the zygomatic eminence (small supraperiosteal boluses). For the medial cheek, a 25G cannula in the deep fat plane minimizes arterial puncture risk. Avoid boluses near the nasojugal fold; favor micro-threads with perfusion monitoring. ^{2 10}

Complications

Infraorbital pain, blanching, or visual symptoms signal possible ophthalmic artery involvement. Activate vascular occlusion and ophthalmology protocols immediately. ^{2 5 7}

5. Nasolabial Fold

Anatomical Overview

The facial artery ascends along the mandibular border before transitioning into the angular artery near the alar base. Depth and course vary by patient, demanding individualised mapping. ^{8 15}

Technique

Approach from lateral entry with a 25G cannula, placing filler either superficially (subdermal) or deeply on bone—never mid-plane. Use linear threading with gentle continuous motion to reduce occlusion risk. ^{2 8 12}

Complications

Signs of vascular compromise (livedo, blanching, severe pain) require immediate massage, heat, high-dose hyaluronidase, and TGA incident reporting if serious. ^{2 5 16}

6. Perioral (Lips & Surrounds)

Anatomical Overview

Superior and inferior labial arteries course within or just below the orbicularis oris, creating high anastomotic risk. The vermillion and white roll planes differ in resistance and vascularity. ^{11 17}

Technique

Select soft, low-G′ fillers. Use small threads in the submucosal plane with gentle aspiration and low pressure. For philtral columns or marionette lines, consider a 25G cannula. ^{2 11 13}

Complications

Blanching, mottling, or pain indicate labial ischaemia; treat immediately with hyaluronidase, massage, warming, and antiplatelet measures per protocol. Escalate ophthalmologically if vision affected. ^{2 5 6 13}

7. Chin

Anatomical Overview

The mental foramen lies below the second premolar, 1.5 cm above the mandible. The mental artery and nerve emerge here, making mid-depth injection hazardous. ¹²

Technique

Inject deeply on periosteum at midline or paramedian points. Avoid the foramen. Use small boluses with aspiration and vertical layering for structure without vascular trauma. ^{2 12 13}

Complications

Potential outcomes include lower lip ischaemia or transient neuropraxia. Record findings and monitor resolution. ^{2 5}

8. Jawline

Anatomical Overview

The facial artery crosses the mandible near the antegonial notch and turns upward. The marginal mandibular nerve runs superficially, prone to oedema or haematoma injury. ^{8 18}

Technique

Inject deep on periosteum lateral to the artery path, preferably with a 22–25G cannula. Avoid mid-dermal boluses near the notch. Proceed slowly with constant aspiration. ^{2 8 17}

Complications

Haematoma, asymmetry, or arterial compromise can occur. Apply compression, reassess, and record corrective actions. ^{2 5 19}

9. Global Safety Principles & Escalation Pathways

Always aspirate before injection where feasible; limit injection rate to ≤ 0.1 mL/s; prefer cannulas in high-risk zones; and maintain immediately accessible anaphylaxis and hyaluronidase kits. Conduct quarterly vascular occlusion and anaphylaxis simulations; document product name, batch, lot, and expiry; report serious events to the TGA (DAEN); and audit annually under NSQHS governance. ^{1 2 4 5 6 19}

Sources

1. AHPRA, Guidelines for registered medical practitioners who perform cosmetic medical and surgical procedures (2025)., viewed 27 October 2025, https://www.medicalboard.gov.au/ ↩
2. ACE Group World, Complications Management Guidelines., viewed 27 October 2025, https://www.acegroup.online/ ↩
3. WHO, Global Patient Safety & Injection Framework., viewed 27 October 2025, https://www.who.int/teams/integrated-health-services/patient-safety ↩
4. ACSQHC, NSQHS Standards: Clinical Governance & Partnering with Consumers., viewed 27 October 2025, https://www.safetyandquality.gov.au/standards/nsqhs-standards ↩
5. TGA, Reporting adverse events & problems (DAEN)., viewed 27 October 2025, https://www.tga.gov.au/reporting-problems ↩
6. Australian Resuscitation Council, Anaphylaxis & Basic Life Support Guidelines (2025)., viewed 27 October 2025, https://resus.org.au/guidelines/ ↩
7. Beleznay K, Carruthers JD, Humphrey S, Jones D. Blindness Following Filler Injection. Plast Reconstr Surg. 2015., Beleznay K, Carruthers JD, Humphrey S, Jones D. Blindness Following Filler Injection. Plast Reconstr Surg. 2015.., viewed 27 October 2025, https://journals.lww.com/plasreconsurg/Fulltext/2015/12000/Blindness_Following_Facial_Filler_Injections.51.aspx ↩
8. Cotofana S, Lachman N. Facial Artery Variation & Clinical Implications. Plast Reconstr Surg. 2019., Cotofana S, Lachman N. Facial Artery Variation & Clinical Implications. Plast Reconstr Surg. 2019.., viewed 27 October 2025, https://journals.lww.com/plasreconsurg/Fulltext/2019/01000/Anatomy_of_the_Facial_Artery__Clinical.25.aspx ↩
9. Lambros V. Temporal Injection Planes. Aesthetic Surg J., Lambros V. Temporal Injection Planes. Aesthetic Surg J.., viewed 27 October 2025, https://academic.oup.com/asj ↩
10. Kwon H et al. Infraorbital Artery Mapping for Safe Midface Augmentation. J Cosmet Dermatol., Kwon H et al. Infraorbital Artery Mapping for Safe Midface Augmentation. J Cosmet Dermatol.., viewed 27 October 2025, https://onlinelibrary.wiley.com/journal/14732165 ↩
11. Jung H et al. Labial Artery Safety in Lip Augmentation. Aesthetic Surg J., Jung H et al. Labial Artery Safety in Lip Augmentation. Aesthetic Surg J.., viewed 27 October 2025, https://academic.oup.com/asj ↩
12. Hwang K et al. Mental Foramen & Artery Safe Zones. J Craniofac Surg., Hwang K et al. Mental Foramen & Artery Safe Zones. J Craniofac Surg.., viewed 27 October 2025, https://journals.lww.com/jcraniofacialsurgery/pages/default.aspx ↩
13. Australian Prescriber, Injectable Fillers & Adverse Events (2023)., viewed 27 October 2025, https://www.ahpra.gov.au/Resources/Cosmetic-surgery-hub/Information-for-the-public/Thinking-about-cosmetic-injectables.aspx ↩
14. OAIC, Australian Privacy Principles: Health Data & Photography., viewed 27 October 2025, https://www.oaic.gov.au/privacy/australian-privacy-principles ↩
15. SafeWork NSW, Sharps and Clinical Waste Safety Standards., viewed 27 October 2025, https://www.safework.nsw.gov.au/ ↩
16. TGA, Australian Regulatory Guidelines for Medical Devices & Advertising Code., viewed 27 October 2025, https://www.tga.gov.au/how-we-regulate/australian-regulatory-guidelines-args/australian-regulatory-guidelines-medical-devices-argmd ↩
17. ACE Group World, Treatment Algorithms for Aesthetic Complications., viewed 27 October 2025, https://uk.acegroup.online/product/ace-group-world-treatment-algorithms/ ↩
18. WHO, Quality of Care & Patient Safety Global Framework., viewed 27 October 2025, https://www.who.int/teams/integrated-health-services/quality-of-care ↩
19. NSQHS, Recognising and Responding to Acute Deterioration (Standard 8)., viewed 27 October 2025, https://www.safetyandquality.gov.au/standards/nsqhs-standards/recognising-and-responding-acute-deterioration-standard ↩