The infraorbital artery: From descriptive anatomy to mucosal perforator flap design

Cadaveric study on the arterial blood supply to the middle third nasal skin: implications for aesthetic and reconstructive surgery

PURPOSE

To provide a detailed examination of the arterial blood supply to the middle third of the nasal skin through cadaveric dissections, identifying the primary arterial sources and their precise locations.

METHODS

Cadaveric dissections were performed on 14 hemifaces from fresh specimens. The main feeding arteries and their branches were carefully dissected under magnification. Morphometric characteristics of the specimens, along with the caliber of the arteries and their branches vascularizing the mid-third nasal skin were recorded, and statistically analyzed.

RESULTS

Four main arteries were identified as responsible for the blood supply to the mid-third of the nasal skin: the facial artery, the nasal branch of the infra-orbital artery (nbIOA), the dorsal nasal artery, and the upper branches of the columellar plexus. The lateral nasal artery (LNA) and the nbIOA were the main contributors, each providing significantly larger arterial branches than the other sources (1.8 ± 0.8 branches of 0.67 ± 0.2 mm for the LNA, p-value < 0.001-1 ± 0 branches of 0.55 ± 0.17 mm for the nbIOA, p-value < 0.01). The largest arterial branch consistently penetrated the lateral and inferior angle of the mid-third nasal skin, originated either from the LNA or nbIOA.

CONCLUSION

The LNA and nbIOA endorse crucial roles in the arterial blood supply to the mid-third nasal skin. Despite the variability in vascular anatomy, a consistent pattern of arterial supply with convergence in the depth of the alarfacial groove was observed. Understanding these patterns is vital for improving surgical precision and reducing the risk of complications in both aesthetic and reconstructive surgeries.

Clinical Relevance of the Variability of the Infraorbital Arterial Anatomy Evaluated by Three-Dimensional Computed Tomography

BACKGROUND

Knowledge of the anatomy of the infraorbital artery (IOA) is crucial for the rejuvenation of the anterior medial aspect of the midface; however, studies adequately describing the anatomy of the IOA branches are lacking, and their connection with the ophthalmic artery branches remains unclear.

OBJECTIVES

This study aims to elucidate the anatomical characteristics of the IOA in its deployment within the lower eyelid using three-dimensional (3D) technology, thereby offering an anatomical foundation for clinical surgical procedures.

METHODS

An analysis was conducted on computed tomography scans of 132 cadaveric head sides post-contrast injection, utilizing the Mimics software for reconstruction. The study focused on examining the anastomosis of the IOA, its principal branches, and the branches emanating from the ophthalmic artery.

RESULTS

The prevalence of type I IOA was observed at 38.6% (51/132), while Type II IOA was found in 61.4% (81/132) of cases. A 7.6% incidence (10/132) of IOA directly anastomosing with the angular artery was noted. The presence of palpebral branches (PIOA) was identified in 57.6% (76/132) of instances. In the lower eyelid, four distinct distribution patterns of IOA were discerned: The likelihood of Type I PIOA was 5.3%, whereas for Types IIA, IIB, and IIC PIOA, the probabilities were 8.3%, 32.6%, and 11.4%, respectively. The occurrence of the orbital branch of IOA was recorded at 41.7% (55/132).

CONCLUSIONS

3D technology can map IOA variants and identify the deployment patterns of IOA branches in the lower eyelid vascular vesicles at high resolution as a guide in clinical practice.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The versatility of the reverse superior labial artery flap

BACKGROUND

The reverse superior labial artery flap was introduced in 2015 as a reconstructive option for medial cheek defects. Notably, this flap can be redesigned as a more effective repair tool for large facial defect reconstruction. In this study, we redesigned the reverse superior labial artery flap to include the vascular territories of the infraorbital and transverse facial arteries in larger sizes for the repair of large facial defects.

METHODS

A reverse superior labial artery flap was used to repair large facial defects in 17 patients with a mean age of 74 years. The defects were located in the orbital region and entirely nasal sidewall in patient two, buccal region in patient three, and in lower lip and malar areas in patient five. The flap sizes ranged from 3.5 × 10 to 7 × 15 cm. A sensory examination was performed on the flaps at 6 and 12 months postoperatively. The mean follow-up period was 12 months.

RESULTS

All flaps survived without partial or total loss. In a small number of flaps minor complications such as venous congestion, epidermolysis, and dehiscence were seen. No functional disability was observed in the lower eyelid or lower lip, and the esthetic appearance was evaluated as satisfactory by the patients. In all the flaps, the protective sensation was recovered in the postoperative 12th month.

CONCLUSIONS

The reverse superior labial artery flap has an extensive arc of rotation, a reliable vascular pedicle, and a large cutaneous paddle. Therefore, this flap may be a versatile surgical repair tool for large cheek defects.

Dynamic region of interest selection in remote photoplethysmography: proof of principle (Preprint)

BACKGROUND

Remote photoplethysmography (rPPG) can record vital signs (VSs) by detecting subtle changes in the light reflected from the skin. Lifelight (Xim Ltd) is a novel software being developed as a medical device for the contactless measurement of VSs using rPPG via integral cameras on smart devices. Research to date has focused on extracting the pulsatile VS from the raw signal, which can be influenced by factors such as ambient light, skin thickness, facial movements, and skin tone.

OBJECTIVE

This preliminary proof-of-concept study outlines a dynamic approach to rPPG signal processing wherein green channel signals from the most relevant areas of the face (the midface, comprising the cheeks, nose, and top of the lip) are optimized for each subject using tiling and aggregation (T&A) algorithms.

METHODS

High-resolution 60-second videos were recorded during the VISION-MD study. The midface was divided into 62 tiles of 20×20 pixels, and the signals from multiple tiles were evaluated using bespoke algorithms through weighting according to signal-to-noise ratio in the frequency domain (SNR-F) score or segmentation. Midface signals before and after T&A were categorized by a trained observer blinded to the data processing as 0 (high quality, suitable for algorithm training), 1 (suitable for algorithm testing), or 2 (inadequate quality). On secondary analysis, observer categories were compared for signals predicted to improve categories following T&A based on the SNR-F score. Observer ratings and SNR-F scores were also compared before and after T&A for Fitzpatrick skin tones 5 and 6, wherein rPPG is hampered by light absorption by melanin.

RESULTS

The analysis used 4310 videos recorded from 1315 participants. Category 2 and 1 signals had lower mean SNR-F scores than category 0 signals. T&A improved the mean SNR-F score using all algorithms. Depending on the algorithm, 18% (763/4212) to 31% (1306/4212) of signals improved by at least one category, with up to 10% (438/4212) improving into category 0, and 67% (2834/4212) to 79% (3337/4212) remaining in the same category. Importantly, 9% (396/4212) to 21% (875/4212) improved from category 2 (not usable) into category 1. All algorithms showed improvements. No more than 3% (137/4212) of signals were assigned to a lower-quality category following T&A. On secondary analysis, 62% of signals (32/52) were recategorized, as predicted from the SNR-F score. T&A improved SNR-F scores in darker skin tones; 41% of signals (151/369) improved from category 2 to 1 and 12% (44/369) from category 1 to 0.

CONCLUSIONS

The T&A approach to dynamic region of interest selection improved signal quality, including in dark skin tones. The method was verified by comparison with a trained observer's rating. T&A could overcome factors that compromise whole-face rPPG. This method's performance in estimating VS is currently being assessed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04763746; https://clinicaltrials.gov/ct2/show/NCT04763746.

False and true accessory infraorbital foramina, and the infraorbital lamina cribriformis

The infraorbital nerve (ION) and artery (IOA) course in the infraorbital canal (IOC) to exit through the infraorbital foramen (IOF). Few previous studies brought evidence of accessory IOF. Evaluation of the IOF in Cone Beam Computed Tomography (CBCT) is more accurate to determine whether or not foramina of maxilla are supplied by canaliculi deriving from the IOC. We performed a retrospective anatomical study of the CBCT files of 200 patients. An accessory infraorbital foramen located inferior to the infraorbital margin (AIOF) was found in 18/200 right maxillae and in 13/200 left ones. Canaliculi deriving from the IOC supplied accessory foramina in the sutura notha- AIOF(SN) - in 15 maxillae. Noteworthy, the AIOF(SN)-negative maxillae displayed the SN and the vascular foramina of Macalister. In 94% of cases the AIOF were unique. A single maxilla (3%) had a double AIOF. In a different case (3%) were found three accessory infraorbital foraminules transforming the anterior wall of the antrum into a veritable lamina cribriformis infraorbitalis. A single prior study distinguished AIOF from AIOF(SN), while most of different other ones were performed on dry bones. Therefore, the reports of prevalence for the number and location of AIOF should be regarded with caution. Foramina of the SN could equally get intraosseous and extraosseous supply, this distinction being accurately made in CBCT.

Facial Blanching after Local Anesthesia Injection: Clinico-anatomical Correlation-Review of Literature

Facial blanching as a complication of local anesthesia is reported in dentistry. Inadvertent arterial penetration and subsequent vasospasm has been accepted as the mechanism of this phenomenon. Most cases occur after inferior alveolar nerve block injection. In this article, five cases are reported after Gow-Gates injection, maxillary nerve block via greater palatine foramen, inferior alveolar nerve block, and maxillary buccal infiltration. It is the largest case series in this topic. Also, clinico-anatomical correlation between facial–mucosal blanching and the site of intra-arterial injection is explained. To the best of our knowledge, partial blanching of the face subsequent to buccal infiltration is reported for the first time in this article. Cutaneous surgeon should be aware of this complication and should not carry out unnecessary treatment.