The transverse facial artery anatomy: Implications for plastic surgery procedures

Anatomic evaluation of the normal variants of the arteries of face using color Doppler ultrasonography: Implications for facial aesthetic procedures

BACKGROUND

Knowledge of normal facial vascular variations could prevent catastrophic complications of cosmetic procedures as well as providing a guide for surgical planning. Color Doppler ultrasound is a safe and noninvasive method for real time vascular evaluation.

OBJECTIVE

The aim of this study was to evaluate the normal variations of the facial, angular, transverse facial, supratrochlear and supraorbital arteries in a sample of normal individuals.

METHODS

Normal individuals referred for dermal filler injection to the tertiary dermatologic center, were selected. Patients who were smoker or had a history of facial filler injection, facial surgery, or trauma were excluded from the study. Facial artery at three levels as well as angular, supratrochlear, supraorbital, and transverse facial arteries were evaluated by an 18 MHz ultrasound linear probe regarding their distance from facial reference lines and landmarks, and also their depths in various regions of face.

RESULTS

A total number of 43 individuals were evaluated in this study. Thirty-one (72.1%) were women. The number of absent facial artery was zero in level one, three (3.48%) in level two, and nine (10.46%) in level three. The angular artery was absent in 10 (11.62%) participants. The transverse facial artery was absent in 27 (31.39%) assessed individuals. Distance from reference lines at level 2 and 3 of facial artery and its depth at level 2 were significantly different between left and right side (p-values: <0.001, 0.01, and 0.03, respectively). No significant difference was seen between depth and distance of two sides for angular and transverse facial arteries. The comparison of the depths and distances from the reference lines of the assessed arteries between two sexes revealed only a significantly greater value of facial artery distance in level 1 in males (p-value: 0.001). BMI was also significantly correlated with the depth of facial artery in level 2 (Pearson correlation coefficient = 0.471, p-value = 0.002) and level 3 (Pearson correlation coefficient = 0.357, p-value = 0.03) and the distance of the facial artery in level 1 (Pearson correlation coefficient = 0.333, p-value = 0.029).

CONCLUSIONS

Color Doppler ultrasound could be used to map the arteries of face to prevent vascular complications and safely guide cosmetic procedures.

Face painting as an anatomical learning tool based on individual ultrasonographic examination

Considering the shift to online education during the COVID-19 pandemic, new and easily accessible educational videos and content on clinical anatomy are necessary. This study utilized numerous references and data on the anatomy of Asian facial muscles and blood vessels to accurately depict human anatomy through face painting. It aimed to provide clinicians accurate educational video content on anatomy to help prevent possible complications during noninvasive facial and surgical procedures. A 26-year-old Korean-Chinese male volunteer was used as a face painting model. The location of the blood vessels of the face was confirmed through ultrasonography images using a real-time two-dimensional B-mode. The model's face was painted by an artist majoring in anatomy. To reveal most anatomical structures on both sides of the face, the left side showed the structures observed when the skin and superficial fat layer are removed, and the right side revealed the deeper layer structures that can be seen when some muscles are cut. Fifteen superficial and deep muscles important in esthetic procedures were meticulously painted on the face. The face painting took a total of 6 h, and the video was edited to 5 min. This study merged the advantages of 2D and 3D by painting directly on the skin surface of a living model. Thus, it can provide more dynamic surface anatomy data. These contents inform clinicians about 3D anatomic location, which can help avoid complications when performing clinical procedures on the face.

The Transverse Facial Artery as a Recipient Artery in Neuroplastic Surgery Microvascular Reconstruction

Microvascular reconstruction in the craniofacial region is particularly challenging due to a paucity of adequate recipient vessels. The facial vessels are commonly utilized; however, in neurocranial reconstruction, the distance from the defect to the vessels may require the use of interposition vein grafts. The superficial temporal vessels, which have the benefit of closer proximity, are often compromised or injured in patients with previous neurosurgical procedures or radiation therapy. Here, we describe the use of the transverse facial artery as a recipient for a latissimus dorsi free flap for scalp reconstruction in a 63-year-old man with a compromised scalp from multiple surgeries and radiation therapy for glioblastoma multiforme. The patient had extensive scarring, temporalis muscle wasting, thinning of the overlying scalp, and notable alopecia. On surveillance imaging, he was found to have an area on the brain concerning for tumor recurrence, for which a surgical biopsy was recommended, with a significant risk of postoperative wound healing complications. We present the use of the transverse facial artery in this case as a recipient artery for free flap reconstruction of the scalp.

An illustrated anatomical approach to reducing vascular risk during facial soft tissue filler administration – a review

Vascular complications from soft tissue fillers can have catastrophic consequences for patients. Adverse events are rare, but they are increasing, and their appearance may be the result of intravascular injection. A comprehensive understanding of the 2-dimensional anatomy (distribution) and 3-dimensional anatomy (depth) of the facial vasculature is fundamental for the safe delivery of nonsurgical cosmetic procedures. The purpose of this review is to provide an illustrated approach to examine surgical anatomy specific to the facial vascular system and the anatomical considerations clinicians need to give in specific danger during injectable cosmetic procedures. A grounding in safety and anatomy will help the new injector to mitigate the risk of vascular complications.

Upper Facial Anastomoses Between the External and Internal Carotid Vascular Territories - A 3D Computed Tomographic Investigation

BACKGROUND

Facial regions with a high risk for causing injection-related visual comprise are dual-supply vascular areas such as the nose, glabella, and forehead. These regions have in common that they receive arterial blood supply both by branches of the internal (ICA) and the external carotid artery (ECA).

OBJECTIVE

The authors sought to investigate the anastomotic pathways between ICA and ECA branches in the upper face.

METHODS

Postmortem computed tomographic angiographic scans of n = 38 Chinese non-embalmed hemifaces (25 males, 13 females; mean age, 37.79 [11.8] years; mean BMI, 21.90 [2.3] kg/m2) were conducted. Data analysis relied on the calculation of depth, distances, and pathways of forehead and temporal arteries to investigate the number of anastomotic connections, the connecting branches, and the layer of connection between ICA and ECA territories.

RESULTS

Between ICA and ECA territories, only 1 connection in 57.9%, 2 connections in 31.6%, 3 connections in 5.3%, and 4 and 5 connections in 2.6% each were identified. A superficial connection was observed in 15.8% whereas in 84.2% the anastomotic connection was identified to be both superficial and deep.

CONCLUSIONS

Adverse events following facial minimally invasive soft-tissue filler injections for aesthetic purposes are not frequent but devastating if they occur. Anatomic knowledge as presented in this study can help to increase awareness of 3-dimensional vascular anastomotic pathways and identify safer injection zones and safer fascial planes. Evidence-based injection techniques should be followed, and safety aspects should be placed over the aesthetic outcome.

Bridging a Century-Old Problem: The Pathophysiology and Molecular Mechanisms of HA Filler-Induced Vascular Occlusion (FIVO)—Implications for Therapeutic Interventions

Biocompatible hyaluronic acid (HA, hyaluronan) gel implants have altered the therapeutic landscape of surgery and medicine, fostering an array of innovative products that include viscosurgical aids, synovial supplements, and drug-eluting nanomaterials. However, it is perhaps the explosive growth in the cosmetic applications of injectable dermal fillers that has captured the brightest spotlight, emerging as the dominant modality in plastic surgery and aesthetic medicine. The popularity surge with which injectable HA fillers have risen to in vogue status has also brought a concomitant increase in the incidence of once-rare iatrogenic vaso-occlusive injuries ranging from disfiguring facial skin necrosis to disabling neuro-ophthalmological sequelae. As our understanding of the pathophysiology of these injuries has evolved, supplemented by more than a century of astute observations, the formulation of novel therapeutic and preventative strategies has permitted the amelioration of this burdensome complication. In this special issue article, we review the relevant mechanisms underlying HA filler-induced vascular occlusion (FIVO), with particular emphasis on the rheo-mechanical aspects of vascular blockade; the thromboembolic potential of HA mixtures; and the tissue-specific ischemic susceptibility of microvascular networks, which leads to underperfusion, hypoxia, and ultimate injury. In addition, recent therapeutic advances and novel considerations on the prevention and management of muco-cutaneous and neuro-ophthalmological complications are examined.

Three-Dimensional Computed Tomographic Study on the Vessels of the Zygomatic Region: Arterial Variations and Clinical Relevance

BACKGROUND

Injection-based techniques for "cheek augmentation" have gained popularity in recent years. The aim of this study was to perform a topographic analysis of the depth and distribution of the vessels in the zygomatic region to facilitate clinical procedures.

METHODS

The external carotid arteries of seven cadaveric heads were infused with lead oxide contrast medium. The facial and superficial temporal arteries of another 12 cadaveric heads were injected sequentially with the same medium. Computed tomographic scanning was then performed, and three-dimensional computed tomographic scans were reconstructed using validated algorithms.

RESULTS

The vessels on the zygomatic arch received a double blood supply from across the upper and lower borders of the arch, and the number of the vessels varied from one to four. Ninety percent of the vessels on the zygomatic arch were at a depth of 1 to 2.5 mm, and 75 percent were at a depth of 10 to 30 percent of the soft-tissue thickness. The vessels were concentrated on the midline of the zygomatic arch and the lateral margin of the frontal process. All samples showed a vessel travel along the lateral margin of the frontal process that eventually merged into the superior marginal arcades.

CONCLUSIONS

This study reported a topographic analysis of the depth and distribution of the vessels in the zygomatic region based on three-dimensional scanning. The results indicated that injection on the zygomatic arch should be performed deep to the bone, and the vascular zones anterior or posterior to the midline of the zygomatic arch were relatively safe injection areas.

Review of the external carotid plexus: anatomy, function, and clinical manifestations

The external carotid plexus is a combination of postganglionic sympathetic fibers derived from the superior cervical ganglion. This plexus travels along the external carotid artery and continues onto the artery’s branches. The external carotid plexus plays an important role in innervating the mid and lower face. Therefore, implications to the plexus may result in facial abnormalities. Herein, we review the anatomy, function, and review its clinical applications.

Topographic Anatomy of the Zygomatico-Orbital Artery: Implications for Improving the Safety of Temporal Augmentation

BACKGROUND

Anatomical knowledge of the zygomatico-orbital artery and its most relevant clinical applications is essential for ensuring the safety of filler injection into the temporal region. The purpose of this study was to provide the precise position, detailed course, and relationship with surrounding structures of the zygomatico-orbital artery.

METHODS

Fifty-eight patients who underwent head contrast-enhanced three-dimensional computed tomography and 10 fresh frozen cadavers were investigated.

RESULTS

The zygomatico-orbital artery was identified in 93 percent of the samples in this work. Ninety-four percent of the zygomatico-orbital arteries derived directly from the superficial temporal artery, and the remaining arteries started from the frontal branch of the superficial temporal artery. According to the origin of the zygomatico-orbital artery, it was classified into type I and type II. Type I arteries were then classified into three subtypes. The trunk of the zygomatico-orbital artery was located between the deep temporal fascia and the superficial temporal fascia. Deep branches of the zygomatico-orbital artery pierced the superficial layer of the deep temporal fascia. The zygomatico-orbital artery originated from 11.3 mm in front of the midpoint of the apex of the tragus, and most of its trunks were located less than 20.0 mm above the zygomatic arch. The mean diameter of the zygomatico-orbital artery was 1.2 ± 0.2 mm. There were extensive anastomoses between the zygomatico-orbital artery and various periorbital arteries at the lateral orbital rim.

CONCLUSION

The precise anatomical knowledge of the zygomatico-orbital artery described in this study could be helpful for cosmetic physicians for improving the safety of temporal augmentation.

Noninvasive Flow Monitoring in Simple Flow Phantom Using Resistive Strain Sensors

In this paper, we introduce a monitoring method for flow expansion and contraction in a simple flow phantom based on electrical resistance changes in an epidermal strain sensor attached to the phantom. The flow phantom was fabricated to have a nonflat surface and small modulus that are analogous to human skin. The epidermal sensors made of polydopamine and polyvinyl alcohol show sufficient linearity (R = 0.9969), reproducibility, and self-adhesion properties, as well as high sensitivity to small modulus measurements (<1% tensile strain). Pulsatile flow monitoring experiments were performed by placing the epidermal sensor on the flow phantom and measuring the relative changes in resistance by the heartbeat. Experiments were conducted for three types of vessel diameters (1.5, 2, and 3 mm). In each of the experiments, the vessels were divided into Top, Middle, and Bottom positions. Experiments for each position show that the relative changes in resistance increase proportionally with the diameter of the vessel. The vessels located close to the epidermal layer have greater relative electrical changes. The results were analyzed using the Bernoulli equation and hoop stress formula. This study demonstrates the feasibility of a noninvasive flow monitoring method using a novel resistive strain sensor.

Transverse facial artery: Its role in blindness after cosmetic filler and botulinum toxin injections

Masseter injections for cosmetic or pathological reasons are increasingly common, as are filler injections using dual or multiplane techniques in the lateral facial regions or for jawline contouring. The occurrence of blindness following these procedures often remains unexplained. This study aimed to determine the anatomical explanation for this debilitating complication by investigating the transverse facial artery and its relation to the masseter. For this purpose, we dissected 35 cheek specimens with latex injections and 10 specimens without latex. The external carotid artery was dissected up to its bifurcation into the maxillary and superficial temporal arteries. Results showed that the transverse facial artery arose from the superficial temporal or external carotid artery that runs between the zygomatic arch and the parotid duct. Three types of transverse facial arteries were observed: type I: a short artery that did not extend beyond the masseter muscle; type II: a transverse artery that ran to the nasolabial fold and anastomosed to the facial artery; and type III: a sizable transverse artery that substituted the hypoplastic facial artery, continued as the angular artery, and then anastomosed to the dorsal nasal artery. Knowledge of these three types of transverse facial arteries is a prerequisite to study the vascular territory. Type III provides an explanation for the occurrence of blindness after lateral face injections. We consequently define a line that runs from the tragus to the outer quarter of the upper lip as the risk area, while the safe zone is located on either side of this line.

Modified V-Y Myocutaneous Flap With Vascular Pedicle for the Repair of Maxillofacial Skin Defects

OBJECTIVE

It is challenging to repair postoperative defect caused by skin tumor resection on the maxillofacial, which not only affects appearance but also impairs functions. To better repair skin defect on the maxillofacial, the application value of V-Y vascular myocutaneous flap was introduced in our study.

METHODS

Between June 2011 and December 2018, 16 patients with maxillofacial skin tumors who received extensive resection were enrolled in our study. The defect on the maxillofacial was repaired by V-Y vascular myocutaneous flap. The follow-up period lasted for 12 to 24 months.

RESULTS

All 16 cases of myocutaneous flaps survived with 1 case of partial venous congestion and 1 case of partial distal necrosis. No recurrence occurred during follow-up. The color and texture of myocutaneous flaps like those of the surrounding skin.

CONCLUSION

Featured with better freeness, larger repair range and aesthetic effect of "kite" flaps, V-Y vascular myocutaneous flap can repair the superior border of zygomatic arch pedicled with facial artery and repair 1.5 cm above the superior border of zygomatic arch pedicled with transverse facial artery for elderly patients in Asia.

A novel technique of arterial blood flow modification in intra-arterial chemoradiotherapy of maxillary sinus squamous cell carcinoma

OBJECTIVES

Intra-arterial chemoradiotherapy via a superficial temporal artery is reportedly a useful organ-preserving treatment for maxillary sinus squamous cell carcinoma. This study aimed to determine whether blood flow modification facilitates sufficient drug delivery to the entire carcinoma via the maxillary artery alone, even for advanced tumors.

MATERIALS AND METHODS

A retrospective study of 10 patients who were diagnosed with locally advanced carcinoma (4 [40%] at stage T3, 5 [50%] at T4a, and 1 [10%] at T4b) from August 2016 to July 2018, with tumor blood flow from both the maxillary and facial arteries, was conducted. Patients underwent intra-arterial chemoradiotherapy, which involved chemotherapy with weekly cisplatin administration (40 mg/m2) and radiotherapy (70 Gy/35 fr), with facial artery ligation. The success rate of blood flow modification, as well as its therapeutic effects and safety, were evaluated, with a median follow-up period of 14.4 months (range: 12.3-35 months).

RESULTS

The blood flow surrounding the tumor was changed from both the maxillary and facial arteries to the maxillary artery alone in all patients. A median of 9 chemotherapy courses (range: 8-10) were administered; the median total cisplatin dose was 350 mg/m2 (range: 320-360 mg/m2). Radiotherapy of 70 Gy/35 fr was used to treat all patients. Grade 3 oral mucositis (80%) and irradiation field dermatitis (40%) were observed. In all patients, complete response was achieved, and local recurrence was not observed for at least 1 year.

CONCLUSION

Simplifying the blood flow around the tumor facilitates more standardized intra-arterial chemoradiotherapy via a superficial temporal artery procedure.