The anatomical origin and course of the angular artery regarding its clinical implications

Three-Dimensional Location of the Facial Artery in Relation to the Nasolabial Fold in Asian People: A Cadaveric CTA Study

BACKGROUND

Injection cosmetics have become popular in recent years. The nasolabial fold is one of the most important and dangerous regions in the midface, and its three-dimensional relationship with the facial artery remains unclear.

METHODS

Fifty-two cadavers infused with lead oxide contrast medium via the external carotid arteries were scanned by computed tomography (CT). The three-dimensional model was reconstructed using Mimics and Origin software, and the relevant data were calculated using validated algorithms.

RESULTS

There were three facial artery types according to its course in relation to the nasolabial fold. In the most common type, accounting for 83.7% of specimens, the facial artery evolves into an angular artery, with a horizontal distance between facial artery and nasolabial fold of - 1.90 ± 2.40, - 3.90 ± 2.95, - 5.18 ± 3.42, - 5.59 ± 3.53, - 5.59 ± 3.83, - 6.07 ± 4.10, - 6.92 ± 3.70, - 6.79 ± 3.37, - 4.52 ± 3.20, and - 2.76 ± 3.60 (mm) from the nasal ala to the oral commissure and a vertical distance of - 4.03 ± 2.56, - 3.27 ± 2.27, - 2.81 ± 2.57, - 2.1 ± 2.64, - 1.5 ± 3.32, - 0.71 ± 3.99, 0.92 ± 4.43, 0.4 ± 5.31, - 4.14 ± 5.14, - 7.05 ± 4.74 (mm).

CONCLUSIONS

The facial artery is vulnerable to damage when injecting filler in the nasolabial fold. For the upper 1/3 of the nasolabial fold, the supraperiosteal layer is recommended for injection, while for the lower 2/3 of the nasolabial fold, the dermal layer along the nasolabial fold is recommended.

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 .

Superimposition Study to Determine the Angular Arterial Distribution and Its Clinical Application

BACKGROUND

The purpose of this study was to determine the distribution of the angular artery (AA) in the medial canthal area with the aim of defining an arterial course to prevent AA injury during facial surgery in this region.

METHODS

The authors dissected 36 hemifaces of 18 cadavers. The horizontal distance from the vertical level through the medial canthus to the AAs was measured. The AA course of each specimen was then recorded, and all of them were then superimposed to determine the AA course. The diameter and depth of the AA around the medial canthal area were also investigated using ultrasonography on living subjects.

RESULTS

The horizontal distances from the medial canthus level and 2 cm below the medial canthus were 9.0 ± 2.0 mm (mean ± SD) and 1.9 ± 2.4 mm, respectively. The superimposed image demonstrated that most of the AAs were present inside the vertical line through the medial canthus. Ultrasonography indicated that the AA was 2.3 ± 0.9 mm below the skin and 1.7 ± 0.3 mm in diameter.

CONCLUSIONS

The AA course was relatively constant along the nasojugal fold. The AAs were most often present between the middle of the medial canthus and the facial midline, but were very scarce in both the medial and lateral thirds. Knowledge of the detailed course of the AA may help surgeons to avoid arterial injury and decrease the risk of surgical morbidities around the nasal root and medial canthal area.

The Efficacy and Safety of Hyaluronic Acid Injection in Tear Trough Deformity: A Systematic Review and Meta-analysis

BACKGROUND

Hyaluronic acid (HA) injection is an effective method to correct tear trough deformity. Nevertheless, the quantitative data of cosmetic results and complications of HA injection in tear troughs remained unemployed. The purpose of this meta-analysis was to synthesize the current quantitative data on the aesthetic outcomes and adverse effects of tear trough deformity correction with HA injection.

METHODS

This meta-analysis consulted PubMed, Embase, Web of Science, Scopus and Cochrane databases based on the search terms published before September 2022. Data extracted was analyzed to evaluate the satisfaction rates and complications of HA injection. Meta-analysis was performed using the random-effect model for overall and subgroup analysis.

RESULTS

This meta-analysis comprised 31 reports involving 2556 participants. The pooled overall satisfaction rate was 91.0% (95% CI 84.9-95.7%). The pooled rates of swelling/edema and bruising/ecchymosis were 19.2% (95% CI 10.4-29.9%) and 18.4% (95% CI 10.1-28.4%), respectively. The pooled rates of redness/erythema, contour irregularity/lump and blue discoloration/Tyndall effect were 7.1% (95% CI 1.5-15.6%), 5.3% (95% CI 1.8-10.2%) and 0.9% (95% CI 0.0-2.5%), respectively.

CONCLUSIONS

The present meta-analysis manifested a low risk of complication rate and a high satisfaction rate in tear trough rejuvenation with HA injection.

LEVEL OF EVIDENCE I

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 .

Hyaluronic Acid Filler Injection Guided by Doppler Ultrasound

Doppler ultrasound can be used to detect almost all arteries of the face before injecting the hyaluronic acid (HA) filler. The relatively more dangerous sites of filler injection are the glabellar wrinkle, forehead, temple, nose, and nasolabial fold area, and it is recommended to map the vasculature of these areas by Doppler ultrasound before performing filler injection. The Doppler ultrasound detection method is included as a video. Internal carotid arterial branches, the supratrochlear, supraorbital, and dorsal nasal arteries, and external carotid arterial branches, the superficial temporal and facial arteries, are very important arteries when injecting HA filler; thus, Doppler ultrasound detection is recommended.

Effectiveness of retrobulbar hyaluronidase in the treatment of visual loss caused by periocular hyaluronic acid injection. A systematic review

INTRODUCTION

Blindness after periocular cosmetic filler injection is a rare but devastating complication. Complication management protocols recommend injecting retrobulbar hyaluronidase if visual loss related to accidental intravascular injection of hyaluronic acid occurs. Given the dramatic increase in cosmetic filler injections and the variety of professionals that can deliver them, it is reasonable to assume that the incidence of complications will rise significantly.

OBJECTIVE

To evaluate if there is evidence-based efficacy of retrobulbar hyaluronidase injection in visual loss secondary to periocular cosmetic filler injection.

MATERIAL AND METHODS

The authors performed a search of English and Spanish language articles following the PRISMA statement published on the use of retrobulbar hyaluronidase to reverse vision loss precipitated by hyaluronic acid gel fillers. Articles reviewed included case reports/series and experimental investigations. We identified a total of 13 patients in this review following defined inclusion and exclusion criteria. Finally, we included 15 articles in the study, 12 of them were cases / case series. The 2 remaining articles are experimental studies in animals with a control group, in which after causing selective occlusion of the ophthalmic artery, serial injections of retroocular hyaluronidase are administered with control of visual function.

RESULTS

Of the 15 articles included in the study, we studied 17 patients treated with retrobulbar hyaluronidase for hyaluronic acid-induced blindness. Improvement was demonstrated in 3 cases. Animal studies demonstrate variable data are provided regarding the recovery of visual acuity.

CONCLUSIONS

There is no confirmed evidence of retrobulbar hyaluronidase injection effectiveness in treating visual loss due to accidental intravascular injection of hyaluronic acid. More studies are needed to show the efficacy of hyaluronidase as a treatment for blindness caused by hyaluronic acid.

Unravelling the Complex Anatomy of the Tear Trough and Lower Eyelid Folds: A Review of Cadaveric Studies in the Literature

The lower eyelid tear trough deformity is a common cosmetic concern which is the result of multiple anatomic changes in the lower eyelid, usually resulting from age. A sound understanding of the underlying anatomy is vital to inform surgeons about the ideal treatment options for rejuvenation of this region and to minimize the risk of complications. Cadaveric studies provide unique insight into underlying anatomic changes. Here we review the relevant published cadaveric studies relating to the tear trough deformity and its treatment.

Surgical Strategies for Eyelid Defect Reconstruction: A Review on Principles and Techniques

Reconstruction of eyelid defects, especially the posterior lamella, remains challenging because of its anatomical complexity, functional considerations, and aesthetic concerns. The goals of eyelid reconstruction include restoring eyelid structure and function and achieving an aesthetically acceptable appearance. An in-depth understanding of the complex eyelid anatomy and several reconstructive principles are mandatory to achieve these goals. Currently, there are multiple surgical treatment options for eyelid reconstruction, including different flaps, grafts, and combinations of them. This comprehensive review outlines the principles of reconstruction and discusses the indications, advantages, and disadvantages of currently available surgical techniques. We also propose our clinical thinking for solving specific clinical questions in eyelid reconstruction and offer perspectives on new potential methodologies in the future.

Expert recommendations on the assessment and management of complications due to hyaluronic acid soft tissue filler injections in Asians

BACKGROUND

The use of hyaluronic acid (HA) fillers for medical aesthetic purposes is increasing worldwide. Nonetheless, adverse events do occur because of patient-specific issues, injection technique, or product factors. It would be mandatory to consider cultural and anatomical features of Asians in preventing and managing the complications of HA injections.

METHODS

Literature search of studies looking at current evidence and guidelines on the management of complications following HA filler injections in Asian patients was conducted. This was followed by an expert group discussion that was convened to reach consensus recommendations on the best clinical practices.

RESULTS

The expert panel provided specific recommendations focusing on the safe use of soft tissue fillers in Asian patients, including early identification of adverse events and how to prevent and comprehensively manage these outcomes.

CONCLUSIONS

Here, we provide consensus statements of Asian experts in dermatology, plastic surgery, ophthalmology, and aesthetic medicine mainly focusing on AEs with higher risk for Asians and can be used to guide physicians in treating Asian population.

Facial Injections and Blindness: A Review on Anatomy

ABSTRACT

With the sudden emergence of new medical aesthetic fillers, the number of fillers injected worldwide has exploded, but there are also worrying risks in the pursuit of beauty. At present, many cases of blindness caused by injection of aesthetic fillers have been reported. Most of the cases are caused by irreversible vascular embolism. This is a rare yet greatly feared complication of using facial cosmetic fillers. This article reviewed and analyzed the literature and summarized the changes in the anatomical structure of facial blood vessels related to blindness during facial injection.

Termination points of the facial artery-A meta-analysis

The facial artery (FA) is the main artery supplying the anterior face, making this artery a very important structure to consider while performing plastic and reconstructive procedures. The literature shows discrepancies in anatomical classifications and the frequency of occurrence of individual variations. Therefore, the goal of this meta-analysis is to provide surgeons with helpful knowledge about the variety of the termination of FA. Articles with data about the termination of the FA were found in major online medical databases such as PubMed, Scopus, Embase, Web Of Science, and Cochrane Library. A total of 1346 articles were initially evaluated by two independent reviewers. Out of those, 24 articles matched the required criteria, and were used in this meta-analysis. A total of 2119 studied FAs were included in this study. The FA termination patterns were divided into five previously classified types. The data show that the FA terminates most frequently as the lateral nasal or angular artery with the prevalence for this group being 69.81% (95% confidence interval [CI]: 59.83%-78.94%). Authors believe that this is the most accurate and up to date study regarding termination patterns and the prevalence of the FA. The results of this meta-analysis could provide a helpful tool for surgeons preforming plastic and cosmetic procedures, especially when injecting dermal fillers or choosing and preforming facial flaps. Detailed anatomical knowledge about the FA may prevent potential surgical complications.

Safety and Effectiveness of Hyaluronic Acid Filler, VYC-20L, via Cannula for Cheek Augmentation: A Randomized, Single-Blind, Controlled Study

BACKGROUND

Using cannulas to deliver facial fillers may reduce adverse events (AEs) compared with needle injection.

OBJECTIVE

To evaluate the safety and effectiveness of VYC-20L (20 mg/mL hyaluronic acid gel with lidocaine) via cannula for midface age-related volume deficit.

MATERIALS AND METHODS

This multicenter, evaluator-blind, randomized, within-subject, controlled study enrolled adults with moderate to severe Mid-Face Volume Deficit Scale (MFVDS) scores. VYC-20L was administered in one cheek via cannula (with optional needle use in the zygomaticomalar region) and in the other cheek via needle. The primary effectiveness end point was the mean (95% confidence interval [CI]) paired difference between treatments in MFVDS score change from baseline to Month 1; an upper CI limit of less than 0.5 determined noninferiority. Injection-site responses (ISRs), procedural pain, and AEs were assessed.

RESULTS

Of 60 randomized and treated subjects, the mean change in MFVDS score from baseline to Month 1 was -1.8 with cannulas and -1.9 with needles, providing a mean (95% CI) paired difference of 0.1 (-0.05 to 0.25). Most ISRs were mild/moderate and resolved within 2 weeks. Procedural pain was minimal, and no serious AEs were reported.

CONCLUSION

VYC-20L for cheek augmentation was safe and effective using a cannula and noninferior to needle injection.

The Course of the Angular Artery in the Midface: Implications for Surgical and Minimally Invasive Procedures

BACKGROUND

Previous anatomic studies have provided valuable information on the 2-dimensional course of the angular segment of the facial artery in the midface and its arterial connections. The third dimension (ie, the depth of the artery) is less well characterized.

OBJECTIVES

The objective of the present study was to describe the 3-dimensional pathway of the angular segment of the facial artery and its relationship to the muscles of facial expression.

METHODS

The bilateral location and the depth of the midfacial segment of the facial artery was measured utilizing multi-planar computed tomographic image analyses obtained from contrast agent-enhanced cranial computed tomographic scans of 156 Caucasians aged a of 45.19 ± 18.7 years and with a mean body mass index of 25.05 ± 4.9 kg/m2.

RESULTS

At the nasal ala, the mean depth of the main arterial trunk was 13.7 ± 3.7 mm (range, 2.7-25.0 mm), whereas at the medial canthus it was 1.02 ± 0.62 mm (range, 1.0-3.0 mm). This was reflected by the arteries' relationship to the midfacial muscles: at the nasal ala superficial to levator anguli oris in 62.0% but deep to the levator labii superioris alaeque nasi in 53.6%; at the medial canthus superficial to the levator labii superioris alaeque nasi in 83.1% and superficial to the orbicularis oculi in 82.7%.

CONCLUSIONS

The results presented herein confirm the high variability in the course of the angular segment of the facial artery. Various arterial pathways have been identified providing evidence that, in the midface, there is no guaranteed safe location for minimally invasive procedures.

An Anatomical Guide to the Terminal Facial Artery: Lumen Diameter and Associated Anatomy Relevant to Dermatologic Procedures

BACKGROUND

Dermal filler injection in the vicinity of the terminal facial artery (FA) can lead to vascular compromise with devastating consequences, including tissue necrosis, blindness, and stroke.

OBJECTIVE

The purpose of this study was to examine lumen diameter and other anatomical features of the terminal FA relevant to dermal filler injection.

MATERIALS AND METHODS

Eighteen embalmed adult cadavers were dissected along the distribution of the terminal FA. Gross and microscopic measurements were taken at predetermined points in its course.

RESULTS

Mean lumen diameter was largest at the midpoint between the oral commissure and the lateral supra-alar crease (0.81 ± 0.36 mm; point P1) and smallest at the midpoint between the lateral supra-alar crease and the medial canthus (0.43 ± 0.23 mm; point P3). Mean cutaneous depth was deepest at the lateral supra-alar crease (5.06 ± 1.84 mm; point P2) and most superficial at the midpoint between the lateral supra-alar crease and the medial canthus (3.13 ± 2.07 mm; point P3).

CONCLUSION

The large-caliber lumen diameter of the terminal FA creates the potential for intra-arterial injection with commonly used filler needles and blunt-tipped cannulas at all points in its course in the nasolabial fold and midface.

Three-Dimensional Description of the Angular Artery in the Nasolabial Fold

BACKGROUND

Due to its arterial vasculature, the nasolabial sulcus is one of the most challenging facial regions to treat when trying to ameliorate the signs of facial aging.

OBJECTIVES

The aim of the present study was to provide data on the 3-dimensional course of the angular artery within the nasolabial sulcus in relation to age, gender, and body mass index to increase safety during minimally invasive treatments.

METHODS

Thee hundred nasolabial sulci from 75 males and 75 females of Russian Caucasian ethnic background (mean [standard deviation] age, 45.7 [18.7] years; mean body mass index, 25.14 [4.9] kg/m2) were analyzed. Bilateral multiplanar measurements were based on contrast-enhanced computed tomography cranial scans.

RESULTS

Up to 3 arteries could be identified within the nasolabial sulcus: ~90% contained 1 arterial trunk, ~9% had 2 trunks, and ~1% had 3 trunks; females had more arteries than men. The artery is located at mean depths of 21.6 mm at the oral commissure and 8.9 mm at the nasal ala. The angular artery was lateral to the nasolabial sulcus in 100% of cases; the smallest distance between the artery and the nasolabial sulcus was at the oral commissure (11.91 [7.9] mm) and the greatest was at the nasal ala (13.73 [3.9] mm).

CONCLUSIONS

In contrast to current concepts, the angular artery is not located strictly subdermal to the nasolabial sulcus but at a variable depth, and in 100% of the investigated cases lateral to the nasolabial sulcus. With increasing age, the depth and lateral distance between arteries and sulci reduces significantly, underscoring the need for special caution when injecting this site.

Rejuvenating the periorbital area using platelet-rich plasma: a systematic review and meta-analysis

Intradermal injection of autologous platelet-rich plasma (PRP) is a non-surgical cosmetic therapy to rejuvenate the periorbital area pathologies of wrinkles, periorbital hyperpigmentation (POH), and photoaging. The past decade has seen the adoption of this novel therapy around the world. This is the first systematic review and meta-analysis evaluating PRP treatment of periorbital pathologies. This is a PRISMA compliant review that includes a comprehensive search of the databases Cochrane Library, Ovid Medline, Ovid Embase, and clinicaltrials.gov. The search was performed in June 2019 to obtain all peer-reviewed articles published in English that describe the application of PRP to periorbital pathologies. A meta-analysis of patient satisfaction was performed for randomized controlled trials. Nineteen studies treating 455 patients (95% female, age range 28-60) were included. Studies were categorized based on reported outcomes: wrinkles (11 studies), POH (7 studies), and photoaging (6 studies). Patients were treated a mean of 3 times (range 1-8) in mean intervals of 23 days (range 14-56 days). Follow-up averaged 3 months (range 1-6 months). Meta-analysis of 3 randomized controlled clinical trials (RCTs) shows that patients treated with PRP have increased satisfaction above controls of saline, platelet-poor plasma, mesotherapy, and as an adjunct to laser therapy (overall effect p = 0.001, heterogeneity I² = 64%). PRP treatment of periorbital area pathologies results in histologic improvements of photoaging, subjective satisfaction score increases, and blind evaluator assessments of rejuvenated skin appearance. Future studies are needed to address limitations of the current literature and should include long-term follow-up, delineation of the POH etiology that is treated, RCTs with low risk of bias, and be absent conflicts of interest or industry sponsors.Trial registration: Prospero Systematic Review Registration ID: CRD42019135968.

Evaluation of facial artery course variations and depth by Doppler ultrasonography

BACKGROUND

As deep nasolabial folds (NLF) are associated with facial aging, there is an increasing demand for esthetic correction with filler injections. Understanding the anatomy of the angular artery (AA) and facial artery (FA) around the NLF region is essential for ensuring the safety of dermal filler injections into the NLF. The purpose of this study was to provide detailed vascular anatomical information on the course and depth of AA and FA around NLF using Doppler ultrasound on live cases.

METHODS

FA was observed from the origin level adjacent to the mandible corpus to the end of its terminal branch AA in 168 hemifaces of 84 cases with Doppler ultrasonography.

RESULTS

We made a classification of the FA course based on the NLF. The minimum and maximum depths of the FA along its course were measured in 84 cases. The results showed that its course may be highly superficial (2.5 mm at the mandibular origin, 3.7 mm at the cheilion, 3.7 mm at the nasal ala) or it may follow a very deep course near the periosteum (15.0 mm at the mandibular origin, 18.7 mm at the cheilion, 23.5 mm at the nasal ala). FA depth was varied between 5.98 mm and 6.62 mm at the mandibular origin, between 8.36 mm and 9.20 mm at the cheilion, between 9.52 mm and 10.51 mm at the nasal ala at a 95% confidence interval.

CONCLUSIONS

This study suggests that there is no absolutely safe depth or region for nasolabial fold filler injections.

Development and Usability of a Virtual Reality-Based Filler Injection Training System

Purpose

As filler procedures have increased in popularity, serious injection-related complications (e.g., blindness and stroke) have also increased in number. Proper and effective training is important for filler procedure safety; however, limitations exist in traditional training methods (i.e. anatomical illustrations and cadaver studies). We aimed to describe the development process and evaluate the usability of a virtual reality (VR)-based aesthetic filler injection training system.

Materials and Methods

We developed the virtual reality hardware for the training system and a short guide, with a lecture regarding safe filler injection techniques. One hundred clinicians who attended a conference tested the training system. Participants completed system usability scale (SUS) and satisfaction questionnaires.

Results

Nearly half of the participants were aged 35–50 years, and 38% had more than 5 years of aesthetic experience. The mean SUS score was 59.8 (standard deviation, 12.23), with no significant differences among the evaluated subgroups. Approximately 76% of participants provided SUS scores of more than 51, indicating acceptable usability. Participants aged 35–50 years were more likely to rate the system as having poor usability than were those aged < 35 years (odds ratio = 5.20, 95% confidence interval: 1.35–20.08).

Conclusions

This study was the first to develop and explore the usability of a VR-based filler training system. Nearly three-fourths of participants indicated that the training system has an acceptable level of usability. However, assessments in precise target audiences and more detailed usability information are necessary to further refine the training system.

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.

Electronic supplementary material

The online version of this article (10.1007/s00266-020-01872-2) contains supplementary material, which is available to authorized users.

Novel technique for infraorbital groove correction using multiple twisted polydioxanone thread

BACKGROUND

The infraorbital groove can be corrected by lower blepharoplasty, microfat grafting, and soft tissue filler injection. Recently, multiple twisted polydioxanone threads were developed for facial rejuvenation.

OBJECTIVE

This study aimed to examine the efficacy and associated risks of the use of new synthetic threads for infraorbital groove correction.

METHODS

From March 2018 to June 2019, 40 patients (mean age: 43.4 years; range: 25-56 years) underwent transcutaneous multiple twisted thread insertion to correct the infraorbital groove. Three threads were inserted along the infraorbital groove on each side. The outcomes were assessed based on a comparison between preprocedure and postprocedure findings. Barton's grading and Global Aesthetic Improvement Scale scores were assessed by two physicians. Patient satisfaction with the aesthetic outcome of the procedure was evaluated at the end of the procedure and after 3 months. Ultrasonographic evaluation was performed to confirm that the threads had been properly placed. The anatomical layer in which the threads were placed was evaluated in a cadaveric study.

RESULTS

The mean Barton grade improved significantly (P < .001) without decline throughout the 12-week period. Improvement was found in all patients who were designated with a score >2 ("improved"). More than 77.5% of the patients were satisfied with the outcomes, and the rest of the patients reported some extent of correction with little satisfaction.

CONCLUSIONS

The findings indicate the benefits of the multiple twisted polydioxanone thread insertion in the treatment of patients with infraorbital groove without septal protrusion. This evaluation raised no major safety concerns.

Anatomical Map of the Facial Artery for Facial Reconstruction and Aesthetic Procedures

BACKGROUND

The facial artery (FA) is the main blood vessel supplying the anterior face and an understanding of its anatomy is crucial in facial reconstruction and aesthetic procedures.

OBJECTIVES

The aim of this study was to assess the many anatomical features of the FA utilizing a multidimensional approach.

METHODS

Head and neck computed tomographic angiographies of 131 patients (255 FAs) with good image quality were evaluated. The FA was classified according to its termination pattern, course, and location with reference to soft tissue/bone surrounding structures.

RESULTS

In total, each branch was present as follows: the submental artery (44.8%), the inferior labial artery (60%), the superior labial artery (82.2%), the lateral nasal artery (25.1%), and the angular artery (42.5%). The most common FA course was the classic course, situated medially to the nasolabial fold (27.1%). In total 65.5% of the arteries were located medially to the nasolabial fold, and only 12.3% of them were totally situated lateral to the nasolabial fold. The median distance (with quartiles) from the inferior orbital rim reached the FA after the superior labial artery branched off in 50.2% of cases and was 36.6 mm (33.4; 43.3). The angle between the FA and the inferior border of the mandible was 49.8o (31.9; 72.4). The horizontal distances between the oral commissure and naris to the FA were 8.5 ± 4.0 mm and 12.1 ± 6.7 mm, respectively.

CONCLUSIONS

An anatomical map summarizing the major measurements and geometry of the FA was generated. The detailed anatomy and relative positioning of the FA should be considered to avoid any unexpected complications in plastic surgery.

Use of handheld ultrasound Doppler to prevent complications from intra-arterial injection of dermal fillers: Clinical experience

A handheld 2 MHz ultrasound Doppler device determines the presence or absence of pulsatile arterial flow immediately beneath the selected site of entry for dermal filler injection. In combination with near infrared technology to map out superficial veins, mishaps from intravascular injections may be reduced. A total of 448 patients aged range between 21 and 74 years, with 168 out of total of 1019 treatment sites having both infrared and ultrasound Doppler assisted preinjection mapping were reviewed. The injection technique is described. Improved patient safety and reduced bruising from asthetic dermal filler injections are potential benefits.

Angular artery island flap for eyelid defect reconstruction

Eyelid reconstruction is a challenging surgical procedure because of the special function and structure of the eyelids. There are various useful techniques which can be used to reconstruct eyelid defects. In this report, the authors aimed to present the clinical results of angular artery-based island flap for the repair of the full thickness eyelid defects. This presented series consists of eight patients with full-thickness eyelid defects. Oncologic resection was the reason for all of them. Five of the patients had lower eyelid defects and the other three had upper eyelid defects. Nasojugal angular artery-based axial flap was used in reconstruction in all patients. The inferior limit of the flap was the alar rim level in order to make the flap totally axial. A tunnel was created under the orbicularis oculi muscle in cases where the medial portion of the eyelids was left intact and healthy. Septal chondromucosal graft was used to repair posterior lamella of the eyelid. The follow-up period of the cases was from 12 months to 22 months, with a mean follow-up period of 16 months. There was only one patient with reconstructed upper eyelid needed flap defatting. There was no ectropion or wound healing problem observed during the follow-up period. This presented series shows that angular artery-based axial flap and septal chondromucosal graft combination is a simple and safe technique for both upper and lower eyelid full-thickness defect reconstruction. The donor site of this flap heals with an inconspicuous scar concealed in the nasojugal area.

Clinical Observations and the Anatomical Basis of Blindness After Facial Hyaluronic Acid Injection

Background

Blindness or visual loss is the most serious complication resulting from facial hyaluronic acid (HA) injection. In this study, three recent clinical cases were analyzed, and the relevant anatomy of cadavers was evaluated to investigate the mechanism behind visual impairment due to HA injection.

Methods

Three patients with different extents of visual loss after HA injection were studied. Ophthalmic testing and corresponding treatments were performed, and the clinical progress was observed. In addition, thirty-six fresh Asian cadaver hemifaces were anatomized to investigate the morphology of the ophthalmic artery and its branches. The minimum dose of HA for central retinal artery embolism was calculated based on the ophthalmic arterial volumes of cadavers.

Results

Visual impairment was more severe in central retinal artery occlusion and combined intraocular branch occlusion than in posterior ciliary artery occlusion. During follow-up, no improvement was observed in terms of visual impairment. Cadaver study reconfirmed that the ophthalmic artery included facial and intraocular branches. The ophthalmic arterial volumes running from the supraorbital artery and supratrochlear artery to the central retinal artery were 0.083 cm³ and 0.089 cm³, respectively.

Conclusions

The severity of blindness caused by HA injection may be associated with the occlusion site. Our clinical observations indicate that conventional treatments, such as retrobulbar hyaluronidase injection, are insufficient to relieve visual impairment. Injecting as little as 0.08 ml of HA into the facial branch is enough to cause central retinal artery embolism. Limiting the volume per injection could represent a simple prophylactic strategy.

Level of Evidence V

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 Role of Anastomotic Vessels in Controlling Tissue Viability and Defining Tissue Necrosis with Special Reference to Complications following Injection of Hyaluronic Acid Fillers

BACKGROUND

Most target areas for facial volumization procedures relate to the anatomical location of the facial or ophthalmic artery. Occasionally, inadvertent injection of hyaluronic acid filler into the arterial circulation occurs and, unrecognized, is irreparably associated with disastrous vascular complications. Of note, the site of complications, irrespective of the injection site, is similar, and falls into only five areas of the face, all within the functional angiosome of the facial or ophthalmic artery.

METHODS

Retrospective and prospective studies were performed to assess the site and behavior of anastomotic vessels connecting the angiosomes of the face and their possible involvement in the pathogenesis of tissue necrosis. In vivo studies of pig and rabbit, and archival human total body and prospective selective lead oxide injections of the head and neck, were analyzed. Results were compared with documented patterns of necrosis following inadvertent hyaluronic acid intraarterial or intravenous injection.

RESULTS

Studies showed that the location of true and choke anastomoses connecting the facial artery with neighboring angiosomes predicted the tissue at risk of necrosis following inadvertent intraarterial hyaluronic acid injection.

CONCLUSION

Complications related to hyaluronic acid injections are intimately associated with (1) the anatomical distribution of true and choke anastomoses connecting the facial artery to neighboring ophthalmic and maxillary angiosomes where choke vessels define the boundary of necrosis of an involved artery but true anastomoses allow free passage to a remote site; or possibly (2) retrograde perfusion of hyaluronic acid into avalvular facial veins, especially in the periorbital region, and thereby the ophthalmic vein, cavernous sinus, and brain.

Three-Dimensional Topography of the Emerging Point of the Ophthalmic Artery

BACKGROUND

During periorbital noninvasive and surgical procedures, there is the risk of iatrogenic injury to the emerging point of the ophthalmic artery. This study aimed to determine the three-dimensional location of the emerging point of the ophthalmic artery and to provide clinicians with anatomical information that would help them to avoid associated complications.

METHODS

Seventeen hemifaces of the emerging point of the ophthalmic artery from 10 Korean and seven Thai cadavers were dissected and scanned by a three-dimensional scanner. The emerging points of the ophthalmic artery of 30 healthy Korean volunteers were also detected using an ultrasound imaging system.

RESULTS

The transverse distance from the medial canthus to the emerging of the ophthalmic artery was 3.8 ± 1.0 mm medially, and the vertical distance was 14.0 ± 2.9 mm superiorly. The transverse distance from the midline was 16.5 ± 1.7 mm to the emerging point of the ophthalmic artery and 20.0 ± 2.0 mm to the medial canthus. The measured depth from the skin surface to the emerging point of the ophthalmic artery was 4.8 ± 1.7 mm by means of three-dimensional scanning and 4.5 ± 1.1 mm using ultrasound detection. The vertical distance from the inferior margin of the superior orbital rim to the emerging point of the ophthalmic artery was 5.3 ± 1.4 mm.

CONCLUSION

These data inform clinicians about the anatomical three-dimensional location of the emerging point of the ophthalmic artery, which will help them to avoid iatrogenic injury when they are performing periorbital clinical procedures.

Anatomic Study of Ophthalmic Artery Embolism Following Cosmetic Injection

INTRODUCTION

Cosmetic injections of dermal fillers or fat could cause ophthalmic artery embolism and even blindness, the high-risk regions of which are considered glabellar, nasal dorsum, and nasolabial fold. Understanding anatomy of the related arteries is important for a physician to safely perform filler injections. To investigate the mechanisms of ophthalmic artery embolism following the injections, cadaver anatomy was studied.

METHODS

Ophthalmic artery, facial artery, their branches, and anastomoses among them were anatomized in 12 fresh cadavers. Mimetic injections of hyaluronic acid were performed in glabellar region, nasal dorsum, and nasolabial fold, the relationships between injected filler and related arteries were then investigated.

RESULTS

It was clearly found that 4 arteries were located in common injection regions and connected to ophthalmic artery: supratrochlear artery, supraorbital artery, dorsal nasal artery, and angular artery. In the glabellar region, the deep injection on the periosteum will be risky to injure supratrochlear artery and supraorbital artery, whereas in nasal dorsum and nasolabial fold, the sub- superficial musculo aponeurotic system layer injection has the possibility to injure dorsal nasal artery, angular artery, and facial artery.

CONCLUSION

The anatomic mechanism of ophthalmic artery embolism is the anastomoses among the related arteries and ophthalmic artery. Based on the findings of the study, injections in periosteum layer at glabellar region or sub-superficial musculo aponeurotic system layer of nasal dorsum and nasolabial fold are not advised.

The facial artery: A Comprehensive Anatomical Review

The facial artery is the major vessel supplying blood to the face so its location and course are very important for the safe manipulation of both surgical and non-surgical interventions. This study documents current anatomical information about the facial artery and its tributaries. The terminology of the facial artery tributaries was revisited with reference to the Terminologica Anatomica and novel nomenclature was suggested with anatomical features. The tributaries to the lower lip (inferior labial artery), labiomental region (horizontal and vertical labiomental artery), upper lip (superior labial artery), nose (inferior and lateral alar artery and nasal septal artery), angular and ocular region (angular artery and detoured branch) and the course, layers and location of the facial artery main trunk were revisited with contemporary anatomical studies. The facial artery and its tributaries have close topographical connections to the facial expression muscles, nasolabial groove, and vermilion border, and these also distinguish facial landmarks comprising the cheilion, stomion, and gonion. Interestingly, in contrast to previous descriptions, some terminal branches did not take a straight course but a detoured course. The angular artery was connected to the ophthalmic artery branches and in some cases did not originate from the facial artery. Vascular complications of the facial artery tributaries are frequently seen in the angular, dorsum of the nose, tip of the nose, and glabellar region. This detailed review focusing on facial arterial topography in the various areas of the face would help to enhance quality of treatment. Clin. Anat. 31:99-108, 2018. © 2017 Wiley Periodicals, Inc.

Topographic Anatomy of the Inferior Medial Palpebral Artery and Its Relevance to the Pretarsal Roll Augmentation

BACKGROUND

A detailed analysis of the topography of the inferior medial palpebral artery is needed to optimize the safety and efficacy of pretarsal roll augmentation.

METHODS

Thirty-one hemifaces from 13 Korean and 8 Thai cadavers (15 male and six female cadavers) were dissected. The distributions of the inferior medial palpebral artery were determined with respect to the superior medial palpebral artery and the supratrochlear artery.

RESULTS

Four distribution patterns were observed. The inferior and superior medial palpebral arteries branched individually from the ophthalmic artery, with the ophthalmic artery terminating as the supratrochlear artery on the forehead (type I); a short trunk branched from the ophthalmic artery and divided into the inferior medial palpebral artery and superior medial palpebral artery, and the ophthalmic artery terminated as the supratrochlear artery (type II); the inferior and superior medial palpebral arteries arose together from the ophthalmic artery, and the ophthalmic artery terminated as the supratrochlear artery (type III); or the inferior and superior medial palpebral arteries were the terminal branches of the ophthalmic artery, with the supratrochlear artery arising from the angular artery (type IV). The diameter of the artery was 0.94 ± 0.22 mm at the entry point and 0.37 ± 0.11 mm at the lateral canthus.

CONCLUSIONS

The inferior medial palpebral artery was located along the tarsal plate deep to the pretarsal part of the orbicularis oculi in the lower eyelid. Injections to augment the pretarsal roll should be made between the subcutaneous tissue and this pretarsal part of the orbicularis oculi.

Periorbital and Intraorbital Studies of the Terminal Branches of the Ophthalmic Artery for Periorbital and Glabellar Filler Placements

BACKGROUND

Filler injections for sunken upper eyelid correction and glabellar augmentation at the orbitoglabellar region need to be performed correctly. Precise knowledge of the emerging sites of all terminal branches of the ophthalmic artery is essential for these procedures to be conducted safely.

METHODS

The terminal branches of the ophthalmic artery were studied in both periorbital and intraorbital dissections. The aim of this study was to verify the critical positions of the emerging sites at the orbital septum that may act as potential retrograde channels for filler emboli.

RESULTS

In the 40 eyes examined, the branches of the ophthalmic artery were found to emerge from four different sites. Two substantial emerging sites were situated on both sides of the trochlea of the superior oblique muscle. These sites were located at the superior part of the medial orbital rim (SMOR) and are alternatively named as the epitrochlear and the subtrochlear emerging sites. The other two sites can be regarded as accessory emerging sites due to the comparably smaller artery. Dissection of the intraorbital region revealed small periosteal branches of the infraorbital artery which coursed anteriorly on the orbital floor to form anastomoses with the lacrimal artery. In other areas of the orbital floor, no branches extended from the infraorbital artery. In front of the lacrimal gland, very minute branches descended and coursed along both margins of the superior tarsus but did not course outside the lateral orbital rim.

CONCLUSION

A danger zone was located at the SMOR, where the ophthalmic branches emerge to form anastomotic channels. Compression at the trochlea guarantees safe injection of filler, reducing the risk of complication.

NO LEVEL ASSIGNED

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 .

Novel Anatomic Description of the Course of the Inferior Palpebral Vein for Minimally Invasive Aesthetic Treatments

BACKGROUND

The inferior palpebral vein (IPV) receives tributaries from the inferior palpebral part of the orbicularis oculi muscle (OOc). The aim of this study was to elucidate the venous distribution pattern of the IPV for dermal filler injection.

MATERIAL AND METHODS

Fifty hemifaces from 34 cadavers were used in this study. The various distribution patterns of the IPV were classified according to its relationship with the angular vein (AV) and facial veins.

RESULTS

The IPV can be classified into the following 4 types: Type I (58.0%), in which the origin of the IPV is located beneath the lateral part of the OOc; Type II (12.0%), in which the origin of the IPV is located beneath the inferior part of the OOc; Type III (8.0%), in which the origin of the IPV is located beneath both the lateral and inferior parts of the OOc; and Type IV (22.0%), in which the IPV is undeveloped.

CONCLUSION

The course of the IPV can be approximated by connecting the lateral orbital rim to the C point (the meeting point between the IPV and the AV). The lateral rim can be palpated and the location of the C point is suggested as a columnar area inferior to the pupil.

Avoiding and Treating Blindness From Fillers: A Review of the World Literature

BACKGROUND

As the popularity of soft tissue fillers increases, so do the reports of adverse events. The most serious complications are vascular in nature and include blindness.

OBJECTIVE

To review the cases of blindness after filler injection, to highlight key aspects of the vascular anatomy, and to discuss prevention and management strategies.

METHODS

A literature review was performed to identify all the cases of vision changes from filler in the world literature.

RESULTS

Ninety-eight cases of vision changes from filler were identified. The sites that were high risk for complications were the glabella (38.8%), nasal region (25.5%), nasolabial fold (13.3%), and forehead (12.2%). Autologous fat (47.9%) was the most common filler type to cause this complication, followed by hyaluronic acid (23.5%). The most common symptoms were immediate vision loss and pain. Most cases of vision loss did not recover. Central nervous system complications were seen in 23.5% of the cases. No treatments were found to be consistently successful in treating blindness.

CONCLUSION

Although the risk of blindness from fillers is rare, it is critical for injecting physicians to have a firm knowledge of the vascular anatomy and to understand key prevention and management strategies.

Patient factors influencing dermal filler complications: prevention, assessment, and treatment

While rare, complications do occur with the esthetic use of dermal fillers. Careful attention to patient factors and technique can do much to avoid these complications, and a well-informed practitioner can mitigate problems when they do occur. Since cosmetic surgery is usually an elective process, requested by the patient, clinical trials are complex to organize and run. For this reason, an international group of practicing physicians in the field of esthetics came together to share knowledge and to try and produce some informed guidance for their colleagues, considering the literature and also pooling their own extensive clinical experience. This manuscript aims to summarize the crucial aspects of patient selection, including absolute contraindications as well as situations that warrant caution, and also covers important considerations for the pre- and posttreatment periods as well as during the procedure itself. Guidance is given on both immediate and long-term management of adverse reactions. The majority of complications are related to accepting patients inappropriate for treatment or issues of sterility, placement, volume, and injection technique. It is clear that esthetic practitioners need an in-depth knowledge of all aspects of treatment with dermal fillers to achieve optimal outcomes for their patients.