Facial foramina and the hidden risks of supraperiosteal filler injections

Objectives: This study aims to anatomically map facial foramina in relation to common supraperiosteal injection points and to assess how real-time ultrasound guidance can enhance safety by visualizing these critical structures. Introduction: Supraperiosteal filler injections are frequently regarded as deep and relatively safe techniques in aesthetic medicine. However, multiple critical neurovascular foramina are distributed throughout the facial skeleton, each transmitting arteries, veins, and nerves that are highly vulnerable to inadvertent injury. Blind injections at the periosteal level, especially near foramina, may lead to severe complications, including vascular occlusion, blindness, or nerve damage. Materials / method: A combined cadaveric dissection and in vivo ultrasound imaging study was performed on 40 hemifaces. The study focused on key foramina including infraorbital, supraorbital, mental, zygomaticofacial, zygomaticotemporal, and several accessory foramina. High-frequency ultrasound was used to identify foraminal locations, vessel emergence patterns, and depth relative to common injection planes. Injection simulations were performed to evaluate the ability of ultrasound to prevent inadvertent vascular or neural injury. Results: Ultrasound reliably identified all major facial foramina and the emerging neurovascular bundles in real time. Many foramina were located within 1–3 mm of common supraperiosteal injection targets, particularly in the infraorbital, pyriform, and mandibular regions. Without imaging, the risk of arterial penetration, hematoma, or nerve trauma was significant. Ultrasound guidance allowed clear visualization of both the periosteal plane and the adjacent foramina, enabling safer needle placement, avoidance of high-risk zones, and confirmation of filler deposition. Conclusion: The presence of facial foramina containing critical neurovascular structures challenges the assumption that supraperiosteal filler injections are inherently low-risk. Ultrasound serves as an essential tool for identifying danger zones in real time, greatly reducing the risk of vascular or neural complications. Adoption of ultrasound-guided techniques should be considered the new standard of care for safe and precise facial filler injections.