A detailed observation of variations of the facial artery, with emphasis on the superior labial artery

An Innovative Preauricular Free Flap Pedicled with Retrograde Vascular for Pediatric Nasal Reconstruction

SUMMARY

Nasal reconstruction in pediatric patients is challenging and requires consideration of later nasal development. The authors introduce an innovative preauricular free flap pedicled with retrograde vascular (PFFPRV) for pediatric nasal reconstruction. In the PFFPRV technique, the retrograde superficial temporal vessels were used as the flap pedicle. The lateral alar artery and angular vein were used as vessels of the nasal recipient zone. The flap vessels were anastomosed directly to the recipient area vessels without additional vessel transplantation. Eight pediatric patients with nasal defects underwent this operation. All patients were followed up for more than 2 years. Medical history data were retrospectively analyzed. Preoperative and postoperative facial photographs were compared and analyzed. Satisfaction of the patients' parents with the aesthetic results was assessed. All patients were successfully operated on without intraoperative complications. None of the procedures required additional blood vessel grafts. One patient developed a vascular crisis the day after surgery and underwent vascular exploration. The free flaps of all patients survived without wound infection or necrosis. The color difference of the flap gradually became non-obvious. The transplanted flap did not show obvious contracture or retraction, and the nose was symmetric and developed well. The parents of all patients were satisfied with the surgical results. The authors think this PFFPRV technique can be a reasonable alternative strategy for reconstruction of pediatric nasal defects, with no adverse effects on nasal development and no need for vascular transplantation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Does Preoperative Vascular Mapping Using Color-Doppler Ultrasound have a Role in the Success of Axial Nasolabial Flap?

Aim

The study was performed to compare the effects of preoperative vascular mapping on the clinical outcome of axial nasolabial flap.

Materials and Methods

A total of 26 patients (29 flaps) were alternately divided into two groups using simple block randomization method. In Group I patients, the conventional axial flap was marked. In Group II, USG-guided flap was designed with the help of Color-Doppler ultrasound. Patients were assessed for a minimum of 6 months and the postoperative flap outcome was quantified using a self-validated composite scoring system. Other parameters of patient morbidity including length of hospital stay, resurgery for reconstruction of secondary defects, postoperative complications were also measured and compared.

Results

The mean postoperative flap outcome score was significantly superior in Group II patients than Group I, at the beginning and at the conclusion of the study (intergroup p-value at postoperative-1-week = .001; at postoperative-1-month = .044; at postoperative-3-month = .139; at postoperative-6-month = .007). Additionally, reconstruction defects with the conventional nasolabial flap were associated with greater morbidity as compared to Group II (intergroup comparison-hospital stay and duration p = .001; complications p = .115; Redo Surgery p = .096).

Conclusion

Therefore, it can be concluded that flap selection based on known dominant perforators could be helpful in achieving favorable outcomes resulting in minimal postoperative morbidity while allowing complex surgical reconstructions.

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.

Analyzing the Anatomical Characteristics of the Facial Artery Branches: A Human Cadaveric Study

OBJECTIVES

The facial artery is the predominant branch of the external carotid artery supplying blood to the head and neck regions. Knowledge regarding the anatomical path and distribution of each facial artery's branches is essential. The aim of the study is to assess the levels, establish the reference positions of each branch of the facial artery to reliable landmarks in the face and neck regions, and evaluate the outer diameter and linear measurement.

MATERIALS AND METHODOLOGY

A prospective single-center cadaveric study was done on 60 hemifaces from 30 properly embalmed and formalin-fixed male cadavers. The statistical analysis was carried out using IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States). Descriptive statistics and inferential statistics have been applied. Nonparametric analysis and the tests of normality were used. The Wilcoxon signed-rank test was used to compare the various parameters between the left and right sides of each branch of the facial artery.

RESULTS

The average length and diameter of each branch of the facial artery measured in millimeters are as follows: superior labial, 27.3 ± 9.17 mm and 1.6 ± 0.2 mm; inferior labial, 31.5 ± 7.86 mm and 1.3 ± 0.6 mm; lateral nasal, 10.6 ± 4.55 mm and 0.74 ± 0.2 mm; angular, 29.65 ± 7.93 mm and 0.8 ± 0.2 mm; and submental, 35.9 ± 5.3 mm and 0.9 ± 0.4 mm. Statistically, there is no remarkable variation between the left and right sides except the submental artery, which shows a remarkable difference based on the origin between the left side and right side with a p-value of 0.039.

CONCLUSION

This study's findings will enable surgeons to more efficiently plan and design reconstructive flaps based on the facial artery, pertaining to this specific ethnic population (Indian origin), which is not available in published history until now.

Quadrifurcation of the Facial Artery Near the Inferior Mandibular Border with a Bilateral Premasseteric Artery Component

During the dissection of the cervicofacial area in a donated male cadaver, an asymmetrical division of the facial artery (FA) and a premasseteric artery (PA) were identified. Specifically, on the left side, the FA stem is divided into four branches (quadrifurcation) 4.26 mm below the lower border of the mandible. In contrast, it is divided into two branches (bifurcation) on the right side. Whether symmetrical or asymmetrical, these variants can have significant implications for rhinoplastic, maxillofacial, or reconstructive surgery. This finding underscores the crucial role of surgeons in exercising caution and paying close attention during these procedures to avoid potential damage.

Identifying Levels of Competency in Aesthetic Medicine: A Questionnaire-based Study

BACKGROUND

In 2022, the US experienced a significant increase in demand for minimally invasive aesthetic procedures, underscoring its rising acceptance amid an unregulated educational environment for practitioners. The absence of standardized educational pathways and quality control in aesthetic medicine, primarily provided by nonacademic institutions, highlights a critical need for establishing educational standards to ensure practitioner competence and patient safety.

OBJECTIVES

The aim of this study was to identify levels of competency for the aesthetic practitioner and necessary achievement milestones during the educational path from novice to expert injector.

METHODS

A total of n = 386 international study participants responded to an online questionnaire regarding their experience in aesthetic medicine practice. The questionnaire comprised 58 questions focusing on professional data, the perceived difficulty of injection, and risk for the occurrence of adverse events for specific facial regions in soft tissue filler and toxin injections.

RESULTS

Regardless of medical specialty and experience level, averages of 3.85 (1.8) years, 786.4 (2628) filler injections and 549.9 (1543) toxin injections were estimated to progress from novice to advanced injector, while averages of 6.10 (3.7) years, 1842.2 (4793) filler injections, and 1308.5 (3363) toxin injections were estimated to advance from advanced to expert injector. The nose and the perioral region have been ranked as the facial regions where it is most difficult to achieve a perfect aesthetic outcome and with the greatest risk for the occurrence of adverse events for filler and toxin injections, respectively.

CONCLUSIONS

In this study we establish an educational framework in aesthetic medicine by defining the progression from novice to competent and expert injector levels, suggesting 4 years of practice and over 790 filler and 550 neuromodulator injections for competence, and at least 6 years with 1840 filler and 1310 neuromodulator injections for expertise. We also identify critical facial regions for targeted treatments by different expertise levels.

LEVEL OF EVIDENCE: 4

Course and Relation of the Facial Vessels-An Anatomical Study

Background and Objectives: Facial vascular anatomy plays a pivotal role in both physiological context and in surgical intervention. While data exist on the individual course of the facial artery and vein, to date, the spatial relationship of the vasculature has been ill studied. The aim of this study was to assess the course of facial arteries, veins and branches one relative to another. Materials and Methods: In a total of 90 halved viscerocrania, the facial vessels were injected with colored latex. Dissection was carried out, the relation of the facial vessels was studied, and the distance at the lower margin of the mandible was measured. Furthermore, branches including the labial and angular vessels were assessed. Results: At the base of the mandible, the facial artery was located anterior to the facial vein in all cases at a mean distance of 6.2 mm (range 0-15 mm), with three cases of both vessels adjacent. An angular vein was present in all cases, while an angular artery was only present in 34.4% of cases. Conclusions: The main trunk of the facial artery and vein yields a rather independent course, with the facial artery always located anterior to the vein, while their branches, especially the labial vessels, demonstrate a closer relationship.

Nasal ala V-Y island flap with a superior vascular pedicle based on inferior perforators of the superior alar artery

For small defects of the anterior nasal ala, a V-Y pedicle advancement flap within the subunit is a useful repair option. Here we propose a modification of this technique, utilising careful dissection to identify inferior perforators of the superior alar artery. Basing this flap on a visualised vascular pedicle aims to prevent common complications of internal mucosal buckling and free margin notching, by allowing more extensive dissection without compromising the vascularity of the flap.

The branching patterns and termination points of the facial artery: a cadaveric anatomical study

BACKGROUND

The facial artery is an important blood vessel responsible for supplying the anterior face. Understanding the branching patterns of the facial artery plays a crucial role in various medical specialties such as plastic surgery, dermatology, and oncology. This knowledge contributes to improving the success rate of facial reconstruction and aesthetic procedures. However, debate continues regarding the classification of facial artery branching patterns in the existing literature.

METHODS

We conducted a comprehensive anatomical study, in which we dissected 102 facial arteries from 52 embalmed and formaldehyde-fixed Vietnamese cadavers at the Anatomy Department, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam.

RESULTS

Our investigation revealed eight distinct termination points and identified 35 combinations of branching patterns, including seven arterial branching patterns. These termination points included the inferior labial artery, superior labial artery, inferior alar artery, lateral nasal artery, angular artery typical, angular artery running along the lower border of the orbicularis oculi muscle, forehead branch, duplex, and short course (hypoplastic). Notably, the branching patterns of the facial artery displayed marked asymmetry between the left and right sides within the same cadaver.

CONCLUSION

The considerable variation observed in the branching pattern and termination points of the facial artery makes it challenging to establish a definitive classification system for this vessel. Therefore, it is imperative to develop an anatomical map summarizing the major measurements and geometric features of the facial artery. Surgeons and medical professionals involved in facial surgery and procedures must consider the detailed anatomy and relative positioning of the facial artery to minimize the risk of unexpected complications.

A Novel Neurovascular Protection Method In Nasolabial Muscle Biomechanical Bionic Surgery For Secondary Unilateral Cleft Lip Repair: A Three-Dimensional Evaluation Of Short And Long-Term Results

BACKGROUND

Neurovascular protection within the upper lip muscles is essential in muscle tension reconstruction and functional recovery during surgery. This study aimed to investigate a novel neurovascular protection method based on the intramuscular neurovascular partitions of the upper lip applied to nasolabial muscle biomechanical bionic surgery for secondary unilateral cleft lip repair and to evaluate postoperative outcomes.

METHODS

From November 30, 2019 to October 31, 2020, 50 consecutive patients with secondary unilateral cleft lips who underwent the modified biomechanical bionic surgery were reviewed retrospectively. Three-dimensional (3D) photographs of patients were collected preoperatively, 7-day postoperatively, and during long-term follow-up (at least 6 months). The Global Aesthetic Improvement Scale was used to evaluate surgical subjective outcomes, and statistical analysis of nasolabial measurements on 3D photographs was used to evaluate objective outcomes before and after surgery.

RESULTS

The Global Aesthetic Improvement Scale showed that 94% of patients had improved upper lip morphology and 92% had improved nasal morphology 7-day postoperatively. In all, 84% maintained favorable nasolabial morphology during long-term follow-up. Statistical results showed that the postoperative alar width, philtral depth, columellar angle, and nasal base inclination angle were significantly improved compared with preoperatively ( P <0.01). The differences between the above 4 indexes were not statistically significant ( P >0.05) between 7-day postoperatively and long-term follow-up, indicating that the postoperative lasting outcomes were satisfactory.

CONCLUSIONS

The novel method of neurovascular protection in nasolabial muscle biomechanical bionic surgery can achieve a long-term improvement of labial-nasal morphology and function in patients with secondary unilateral cleft lip.

Uncommon Anatomical Variation of the Facial Artery: A Cadaveric Case Report

The facial artery is a branch of the external carotid artery, one of the major arteries supplying blood to the head and neck. The normal route of the facial artery follows a well-defined path. It typically arises from the external carotid artery, above the superior border of the hyoid bone. During its route, the facial artery gives off branches in the neck, mandible, buccal region, and face. This case report explores a rare anatomical variation of the facial artery characterized by an unusual termination point above the upper lip as the superior labial artery, found during a routine cadaveric dissection. While variations in the course of the facial artery are documented, this particular deviation, with its termination anterior to the typical endpoint, presents a unique anatomical variation.

Facial artery: anatomical variations in the perioral region in cadavers

BACKGROUND

In recent years, there has been an increase in reports of perioral vascular complications resulting from filler injections, such as necrosis of the lip or alar rim, occlusion, and in severe cases, blindness. Conversely, the use of perioral arterial flaps is becoming more prevalent in the treatment of cleft lips, cancer, and trauma. A thorough understanding of perioral arteries is essential to minimize complications and maximize the success of these flaps. However, the course of the facial artery (FA) in the perioral region remains incompletely understood. The aim of this study was to describe the variations of the FA in the perioral region.

METHODS

We dissected 52 embalmed and formaldehyde-fixed Vietnamese cadavers. We then studied the size and distribution of perioral arteries in 102 specimens.

RESULTS

The superior labial artery (SLA) was the most common branch, occurring in 87.25% of cadavers, followed by the inferior labial artery (ILA) at 78.43%. The SLA primarily originated above the mouth corner (cheilion), accounting for 91.01% of cases, and predominantly exhibited a tortuous course within the submucosa (78.65%). The ILA's branching pattern varied, but it was primarily located below the cheilion (91.25%). The ILA also followed a twisted path, generally within the submucosa. The ILA exhibited two patterns: the typical pattern, distributed at the vermilion border of the lower lip (8.82%), and the horizontal labiomental artery pattern, which ran horizontally in the middle of the lower lip area (69.61%). At their origin, the SLA and ILA had average external diameters of 1.29 mm and 1.28 mm, respectively.

CONCLUSION

Numerous anatomical variations in the FA in the perioral region were found. A detailed anatomic description, suggested landmarks, and angiography before the procedure will be useful to help doctors avoid complications.

Submandibular Gland Excision with Facial Artery Preservation: The Argument for Changing the Established Norms

To evaluate the difference in average operating time and intraoperative blood loss in transcervical submandibular gland excision for isolated benign submandibular diseases, while preserving the facial artery and ligating the facial artery. A prospective study was conducted in our institute for a duration of 6 months from January 2022 to June 2022. 30 patients undergoing excision of the submandibular gland as an isolated procedure were included. They were randomly divided into 2 groups of 15, Group "A" where the facial artery was preserved, and "B" where the artery was ligated. The operating time in minutes and intra operative blood loss was compared. The mean operating time was 48.26 min in Group A, and 46.2 min in Group B. The p value between the two groups was 0.189586, which was not significant. The mean blood loss in group A was 44.6 ml, and 45.8 ml in group B. The p value was not significant at 0.331254. Preserving the facial artery in benign tumours while excising the gland neither increases operating time nor intraoperative bleeding. This will not only retain the anatomy, but provide a second option for flap reconstruction in case needed later.

Evaluation of facial artery course variations, diameters, and depth by Doppler ultrasonography

BACKGROUND

The facial artery (FA) is the main blood vessel supplying blood to the face. It is essential to understand the anatomy of FA around the nasolabial fold (NLF). This study aimed to provide the detailed anatomy and relative positioning of FA to help avoid unexpected complications in plastic surgery.

METHODS

FA was observed from the inferior border of the mandible to the end of its terminal branch in 66 hemifaces of 33 patients with Doppler ultrasonography. The evaluation parameters were: (1) location, (2) diameter, (3) FA-skin depth, (4) relationship between the NLF and FA, (5) distance between the FA and significant surgical landmarks, and (6) the running layer. The FA course is classified based on the terminal branch.

RESULTS

The most common FA course was Type 1, which had an angular branch as the final branch (59.1%). The most common FA-NLF relationship was that the FA was situated inferior to the NLF (50.0%). The mean FA diameter was 1.56 ± 0.36 mm at the mandibular origin, 1.40 ± 0.37 mm at the cheilion, and 1.32 ± 0.34 mm at the nasal ala. The FA diameter on the right hemiface was thicker than that on the left hemiface (p < 0.05).

CONCLUSION

The FA mainly terminates in the angular branch, running in the medial NLF and in dermis and subcutaneous tissue, with a blood supply advantage in the right hemisphere. We suppose that a deep injection into periosteum around the NLF may be safer than an injection into the superficial musculoaponeurotic system (SMAS) layer.

The Course and Variation of the Facial Vein in the Face-Known and Unknown Facts: An Anatomical Study

Background and Objectives: The facial vein is the main collector of venous blood from the face. It plays an important role in physiological as well as pathological context. However, to date, only limited data on the course and tributaries of the facial vein are present in contemporary literature. The aim of this study was to provide detail on the course and the tributaries of the facial vein. Materials and Methods: In 96 sides of 53 body donors, latex was injected into the facial vein. Dissection was carried out and the facial vein and its tributaries (angular vein, ophthalmic vein, nasal veins, labial veins, palpebral veins, buccal and masseteric veins) were assessed. Results: The facial vein presented a textbook-like course in all cases and crossed the margin of the mandible anterior to the masseter in 6.8% of cases, while being located deep to the zygomaticus major muscle in all cases and deep to the zygomaticus minor in 94.6% of cases. Conclusions: This work offers detailed information on the course of the facial vein in relation to neighboring structures, which shows a relatively consistent pattern, as well as on its tributaries, which show a high variability.

A Case Report: An Unusual Variation in the Facial Artery

The facial artery is the main artery supplying the face occasionally. It gives three branches on the face, the inferior labial, the superior labial, and the lateral nasal, and terminates as the angular artery. Due to congenital vascular variations in the facial artery, it has been considered in the dissection of the head and neck region. During the dissection of a 65-year-old woman to expose this region, we discovered that the left facial artery is terminated by the superior labial artery after giving off the submental and inferior labial branches. At the level of the left oral commissure, the facial artery was attached to the buccinator muscle as connective tissue, with a noticeable decrease in diameter. The purpose of this study is to report a new variation of the facial artery that is particularly important for cadaver dissection, and head and neck surgeries, as well as for facial artery angiography.

Neurovascular territories of the canine fossa: Analysis of a South African population

BACKGROUND

The canine fossa, a depression on the surface of the maxillary bone, is important clinically due to the nexus of the neurovascular elements which occur in this region and supply the superficial and deep structures of the face. While it is known that there is much variation in the neurovascular structures of this region, little is known about sex differences. The aim of this study was to investigate and map the neurovascular branching within the region of the canine fossa of a South African population, with particular reference to any sex differences.

METHODS

Sixty hemifaces (n=30 female; n=30 male) of individuals between the ages of 40 and 100years were dissected. The origin, number of branches, connections between branches, origin of connecting branches and the distribution of the neurovascular structures associated with the mid-facial and canine fossa regions were documented. The data obtained was qualitative and was statistically analysed with SPSS v26 statistical analysis software. Frequency and contingency tables, along with Chi-squared analysis and Fischer's Exact test, were used for quantitative data analysis.

RESULTS

While high levels of variation in the neurovascular elements were documented, there was no statistically significant variation between the sexes. A sex variation was only observed for the terminal branches of CN VII with females displaying a lower number of buccal nerve terminal branches than males.

CONCLUSION

While only one sex difference of significance was found in the highly variable neurovascular structures resident in the region of the canine fossa, the variability of the neurovascular elements is of importance to surgeons.

Application of Modified Triangular Perforator Flap in Repair of Small and Medium-Sized Facial Defect

Background

We investigated the application of local perforator flap or island flap with a modified triangular to repair small and medium facial defects.

Methods

(1) Before the operation, a Doppler flowmeter was used to investigate the superficial exit point of the perforator artery. The length to breadth ratio of the flap was more than 3-4 times, and it contained 1-2 perforator vessels. (2) The lesion was excised, and the skin was cut along the design line of the flap. The flap was separated and trimmed based on the defect degree. (3) The blood supply was confirmed, and the defect was then covered with the flap by "rotation and advancement" approach without causing tension. The incision was finally sutured in layers. (4) Postoperative routine care was performed according to the situation.

Results

The functional morphology and appearance of all 23 cases of skin flaps successfully recovered during follow-up. There was no major aesthetic and malformation recorded.

Conclusion

In summary, the modified triangular perforator flap can improve the functional appearance at the repaired small and medium facial defects.

Facial Arterial Variations in Asians: A Study on Computed Tomographic Angiography

BACKGROUND

A consensus on facial artery anatomy has not been established due to the discrepancies in previous studies.

OBJECTIVES

The authors sought to assess the branches, course, and location of the facial artery in Asians by utilizing computed tomographic angiography.

METHODS

The computed tomographic angiography images of 300 facial arteries from 150 Asian patients were evaluated. The FA was classified as follows: type 1, facial artery terminates superior labial or inferior labial artery; type 2, facial artery terminates lateral nasal or inferior alar artery; type 3, facial artery terminates medial canthal artery; or type 4, facial artery is divided into duplex branches with dominant medial canthal artery laterally. The relationship between nasolabial fold and FA was evaluated, and the distances from anatomical landmarks to FA were measured to position the course.

RESULTS

Seventy (23.3%), 163 (54.3%), 49 (16.3%), and the other 18 arteries (6.0%) were classified as type 1, 2, 3, and 4, respectively. A total 72.3% of facial arteries were located medially to the nasolabial fold, and only 14.7% of arteries were lateral to the nasolabial fold. The vertical distance between the facial artery and the inner canthus or the midpoint of the inferior orbital rim decreased from type 1 to type 4 facial artery (P < 0.0001). The 4 types did not significantly differ in distance between the mandibular angle (P = 0.1226) or oral commissure (P = 0.1030) and the facial artery at inferior of mandible.

CONCLUSIONS

Detailed findings of the facial artery will provide a valuable reference for filler injection in cosmetic procedures and flap design in reconstructive surgery.

Accelerated Two-Point Dixon MR Angiography Improves Diagnostic Performance for Cervical Artery Diseases

BACKGROUND

Nonenhanced MR angiography (MRA) studies are often used to manage acute and chronic large cervical artery disease, but lengthy scan times limit their clinical usefulness.

PURPOSE

To develop an accelerated cervical MRA and test its diagnostic performance.

STUDY TYPE

Prospective.

POPULATION

Patients with cervical artery disease (n = 32, 17 males).

FIELD STRENGTH/SEQUENCE

3.0 T; accelerated two-point Dixon three-dimensional Cartesian spoiled gradient-echo (FLEXA) and conventional time-of-flight MRA (cMRA) sequences.

ASSESSMENT

All patients underwent FLEXA (1'28″) and cMRA (6'47″) acquisitions. Quantitative evaluation (artery-to-background signal ratio and a blur metric) and qualitative evaluation using diagnostic performance measured by the sensitivity, specificity, and positive/negative predictive values (PPV/NPV), and vessel and plaque visualization scores from three board-certified radiologists' (with 10, 11, and 12 years of experience) independent readings using maximum intensity projection (MIP) for luminal diseases and axial images for plaque. The reference standards were contrast-enhanced angiography and fat-saturated T1-weighted images, respectively.

STATISTICAL TESTS

All measures were compared between FLEXA and cMRA using the paired t, Wilcoxon signed-rank, McNemar's, or chi-squared test, as appropriate. Interreader agreement was assessed using Cohen's κ. P < 0.05 was considered statistically significant.

RESULTS

The artery-to-background signal ratio was significantly higher for FLEXA (FLEXA: 7.20 ± 1.63 [fat]; 4.26 ± 0.52 [muscle]; cMRA: 2.57 ± 0.49 [fat]), while image blurring was significantly less (FLEXA: 0.24 ± 0.016; cMRA: 0.30 ± 0.029). In luminal disease detection, sensitivity (FLEXA: 0.97/0.91/0.91; cMRA:0.71/0.69/0.63), specificity (FLEXA: 0.98/0.93/0.98; cMRA:0.93/0.85/0.92), PPV (FLEXA: 0.92/0.86/0.86; cMRA: 0.64/0.5/0.58), and NPV (FLEXA: 0.99/0.98/0.98; cMRA: 0.92/0.91/0.9) were significantly higher for FLEXA. interreader agreement was substantial to almost perfect for FLEXA (κ = 0.82/0.86/0.78) and moderate to substantial for cMRA (κ = 0.67/0.56/0.57). MIP visualization scores were significantly higher for FLEXA, with substantial to almost perfect interreader agreement (FLEXA: κ = 0.83/0.86/0.82; cMRA: κ = 0.89/0.79/0.79). In plaque detection, sensitivity (FLEXA: 0.9/0.9/0.7; cMRA: 0.3/0.6/0.2) and specificity (FLEXA: 1/0.87/1; cMRA: 0.93/0.63/0.97) were significantly higher for FLEXA in two of three readers. The interreader plaque detection agreement was fair to substantial (FLEXA: κ = 0.63/0.69/0.48; cMRA: κ = 0.21/0.45/0.20). Side-by-side plaque and vessel wall visualization was superior for FLEXA in all readers, with moderate to substantial interreader agreement (plaque: κ = 0.73/0.73/0.77; vessel wall: κ = 0.57/0.40/0.39).

DATA CONCLUSION

FLEXA enhanced visualization of the cervical arterial system and improved diagnostic performance for luminal abnormalities and plaques in patients with cervical artery diseases.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 2.

Visualising the individual arterial anatomy of the face through augmented reality - a useful and accurate tool during dermal filler injections

Background

The arterial anatomy of the face is extremely variable. Despite numerous cadaver dissections and anatomical descriptions, the exact location of the superficial facial arteries remains unpredictable. This ignorance is a determining factor in the pathophysiology of intravascular filler injections, potentially causing skin necrosis and blindness.

Objectives

The main objective of this study is to evaluate the accuracy of an augmented reality (AR) application that visualizes the individual arterial anatomy of the face.

Methods

A workflow was developed during which a magnetic resonance angiography (MRA) mapped the superficial arteries of the face. The images were further processed into an AR image that was visualized on the patient’s face using a specifically designed smartphone application. The accuracy of the AR image and the position of each individual artery were analyzed using duplex ultrasound (US).

Results

A total of 216 facial arteries were visualized in 20 patients. The superficial temporal (100%), supratrochlear (92.5%), facial (75%), and angular (82.5%) arteries were visualized the most. The inferior labial (17.5%), dorsal nasal (22.5%), and supraorbital (42.5%) arteries were the most difficult to visualize through MRA. The average deviation between the artery visible on the AR image and the location assessed by US was 0.30 mm (standard deviation = +/− 0.66 mm). There were no complications reported.

Conclusions

The combination of a risk-free MRA to map the individual arteries of the face and the processing into an AR image may be considered as a useful and accurate tool during dermal filler injections to potentially minimize the risk of intravascular filler injections.

Descriptive Study on Vascular Anatomy of the Upper Lip

INTRODUCTION

The superior labial artery (SLA) is a facial artery (FA) that drains into the peri-oral region (dangerous area of face). Owing to the recent rise in the demand for reconstructive procedures and filler injections in this region, it is important to understand its arterial topography. This paper aims to study the embranchment pattern of the labial arteries in the eastern Indian population.

METHOD

An observational study using conventional dissection and dry dye injection methods was conducted to visualize the facial and superior labial arteries in 56 hemifaces. The origin, morphometry (length and diameter), branching pattern, and termination of the arteries were recorded and compared with the existing data.

RESULTS

Two hemifaces were excluded from analysis (vessels damaged in dissection); in the remaining 54, a single SLA was present in all samples originating at a mean distance of 1.29 ± 0.32 cm from oral commissure (68.51% originating above). Lee type II (independent SLA giving off alar branch) was the predominant pattern (56.2%), followed by type I (independent SLA and alar branches, 33%) and type III (FA terminating as SLA, 10.8%). The average length of SLA was 4.75 ± 1.28 cm and 4.56 ± 0.78 cm on the right and left sides, respectively.

CONCLUSION

The SLA is highly variable in occurrence, course, and depth, sometimes even occurring unilaterally; therefore, any intervention in this region should be done with caution. Since the SLA was not found subcutaneously at the vermillion border, the intradermal and the subcutaneous injections used here are relatively safer.

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 .

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.

A Rare Case of Facial Artery Branching-A Review of the Literature and a Case Report with Clinical Implications

Background and Objectives: Vascular variations appear as morphologically distinct patterns of blood diverging from the most commonly observed vessel patterns. The facial artery is considered to be the main vessel for supplying blood to the anterior part of the face. An anatomical understanding of the facial artery, its course, its topography, and its branches is important in medical and dental practice (especially in neck and face surgery), and is also essential for radiologists to be able to interpret vascular imaging in the face following angiography of the region. A profound knowledge of the arteries in the region will aid in minimizing the risks to the patient. Materials and Methods: In our publication a narrative literature review and a case report are presented. Results: A rare case of a facial artery pattern has been described anatomically for the first time with respect to its course and branching. This variation was found on the left side of a 60-year-old male corpse during anatomical dissection. The anterior branch of the facial artery arched in the direction of the labial angle, and there divided into the inferior and superior labial arteries. At the same time, the posterior branch coursed vertically and superficially to the masseter muscle. It here gave off the premasseteric branch, and continued towards the nose, where it ran below the levator labii superioris and the levator labii superioris alaeque nasi muscles and terminated at the dorsum nasi. Conclusions: Our review of the literature and the case report add to knowledge on the facial artery with respect to its topographical anatomy and its branching and termination patterns, as well as the areas of supply. An exact knowledge of individual facial artery anatomy may play an important role in the planning of flaps or tumor excisions due to the differing vascularization and can also help to prevent artery injuries during aesthetic procedures such as filler and botulinum toxin injections.

Prevention and Management of Filler Induced Iatrogenic Stroke of the Eye

In the past few decades, minimally-invasive esthetic treatments and the use of injectable Hyaluronic Acid Gels and other filling agents to treat facial esthetics have increased dramatically. Although extremely rare, a filler can cause ocular and orbital ischemia by retrograde flow from the ophthalmic artery when injected in any of the anastomosis of the face. Once filler reaches the central retinal artery, blindness is inevitable, and no treatment is effective. While the risk of blindness happening with any filler injection is rare, the life-altering irreversible consequence of a procedure that was anticipated to be simple and beautifying is a reality that each injector must be prepared for with every injection. The parameters associated with an iatrogenic stroke of the eye are the site of injection, the injection technique, patient characteristics, and the material injected. Understanding the interplay of each of these variables might help us reduce the possibility of blindness during the injection of a soft-tissue cosmetic filler. Here, we explore the causes of Hyaluronic Acid Gels Filler embolic phenomena, review the natural course of the process, and discuss appropriate immediate interventions. We also (1) propose an education plan for injectors and describe how to carry out a focused ophthalmologic examination and procedural activities for a referral to an ophthalmologist, (2) outline steps to prevent emboli during filler injection, and (3) how to manage and support a patient with a sudden loss of vision during or immediately after a Hyaluronic Acid Gels filler treatment.

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.

Trifurcation of the facial artery at the inferior border of the mandible: a case report

PURPOSE

The facial artery is known to show variations in its origin, course, termination, and branching pattern. This study aimed to present a case with trifurcation of the facial artery at the inferior border of the mandible accompanied by variable branches.

METHODS

During our routine head dissection, it was observed that a 67-year-old male cadaver had a trifurcation of the facial artery at the level of the lower border of the mandible on the left. The skin was reflected, and the subcutaneous fatty tissue and subcutaneous layers were dissected to reveal the triple facial artery.

RESULTS

The left facial artery arising from the external carotid artery entered the face with three branches as it crossed the lower border of the mandible. The three branches are the anterior, intermediate, and posterior branches. The posterior branch passed in front of the anterior border of the masseter muscle along with the facial vein and gave off muscular branches with a straight course, whereas the anterior thickest curved branch terminated by the inferior labial artery, and a tortuous intermediate branch initially gave off the superior labial artery and then terminated by the angular artery.

CONCLUSION

Understanding these variational branches of the triple facial artery and their relationships is crucial for avoiding complications in reconstructive and reparative maxillofacial, craniofacial and plastic surgery in order to mitigate the risk of damage to the facial artery during flap surgery.

One-Stage Reconstruction of the Large Lower Nose Defect Involving 2 Subunits With Lateral Nasal Artery Pedicle Nasolabial Flap

BACKGROUND

Large nose defect reconstructions involving the tip and alar subunits are still difficult to achieve in one stage. This study aimed to investigate the size of the nasal tip and alae, observe the distribution patterns of the lateral nasal artery and present our clinical experience with the lateral nasal artery pedicle nasolabial (LNAPN) flap.

METHODS

From June 2019 to January 2020, lower nose parameters from 60 subjects were measured by a 3-dimensional scan, and the cranial digital subtraction angiogram results of 20 patents without vascular malformation were retrospectively analyzed. The case series consisted of four patients with nasal tip and alar defects who underwent surgery with LNAPN flaps from December 2018 to June 2019. Outcomes and complications were followed-up at 6 to 12 months.

RESULTS

For the 3-dimensional scan study, the mean area of the 2 subunits involving the tip and alae was 7.986 ± 1.728 cm. In the digital subtraction angiogram data, the lateral nasal artery was identified among all facial arteries and had a mean diameter of 1.0 ± 0.20 mm. Sixteen people (80%) had a rich connection between the lateral nasal artery and the transverse facial artery. All cases revealed satisfactory aesthetic outcomes by reconstruction of large defects in one stage. The largest flap of 4.2 cm × 3.0 cm in our study showed complete healing.

CONCLUSIONS

The LNAPN flap represents a feasible, flexible, efficient, and easily mastered reconstructive method for large nose defects involving the tip and alar subunits.

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.

The Premasseteric Branch of the Facial Artery: A Review and Translation of Adachi's Work

The premasseteric branch of the facial artery is a variable posterior branch that is closely associated with the anterior border of the masseter muscle. Since its first description, the premasseteric branch has been described using different terms such as the masseteric or posterior branch of the facial artery. While the artery’s anatomy is known, it is infrequently discussed in the literature. This manuscript reviews the artery’s origin, course, and importance during maxillofacial procedures, especially those involving manipulation of the masseter. We also provide a translation of Adachi’s 1928 German text describing the branch.

Variant facial artery anatomy revisited: Conventional angiography performed in 284 cases

A number of studies have evaluated the variable courses of facial artery. However, the results of these differed substantially from each other so not consistent relationships have yet been established. There has also yet to be a relevant study using conventional angiography.We assessed the variant branching pattern of the facial artery and its branches using conventional angiography.Two radiologists retrospectively reviewed 284 cases of angiographies of the external carotid artery in 198 patients. The courses of the facial artery and infraorbital branch of the maxillary artery were classified into 4 types and 2 types, according to the end branch.Among 284 cases of facial artery, type 1 (angular branch) made up 104 cases (36.6%), type 2 (lateral nasal branch) made up 138 cases (48.6%), type 3 (superior labial branch) made up 24 cases (8.5%), and type 4 (inferior labial branch) made up 18 cases (6.3%).Regarding the 284 total cases of maxillary artery, 163 cases (57.4%) had anastomosis with the angular artery or extended to the territory of the angular artery. In addition, 121 cases (42.6%) had nothing done in regard to the angular artery.The results may be helpful for avoiding complications related to facial and maxillary arteries during facial surgeries and cosmetic procedures.

Infrared Thermally Enhanced 3-Dimensional Time of Flight Magnetic Resonance Angiography Imaging for the Visualization of the Arteries of the Face

Background

The face is known for its extreme variation in vascular anatomy. Furthermore, the rapidly increasing number of filler treatments leads to an increase in severe filler-associated complications (such as skin necrosis and blindness) due to intra-arterial injection. Visualizing a patient’s individual complete facial arterial anatomy in a contrast- and radiation-free way has not been published before. This innovative imaging technique could, therefore, enhance the safety of minimally invasive surgical procedures as it provides a harmless way to map the arteries of the face.

Objectives

Evaluate a newly developed imaging technique to visualize the arteries of the face in a noninvasive and radiation-free manner.

Methods

The individual arterial facial anatomy of 20 volunteers was studied by an imaging technique, combining infrared (IR) facial warming and 3-dimensional (3D) time of flight (TOF) magnetic resonance angiography (MRA). The source and maximum intensity projection images were assessed by 2 investigators, familiar with the anatomy of the face.

Results

The MRA technique visualized most of the main facial arteries, albeit in a variable way. The main facial branches of the external carotid artery (facial, angular, supralabial, and superficial temporal arteries) were illustrated well, whereas the visualization of the internal carotid branches (supratrochlear and supraorbital arteries) and nasal branches (dorsal nasal and lateral nasal arteries) was less consistent.

Conclusions

The combination of IR “heat-induced enhancement” and a 3D-TOF MRA sequence may actually be an important step toward the visualization of the variable facial vascular anatomy in a noninvasive, radiation-free, and contrast-free manner.

Three-dimensional visualization of blood supply of the upper lip using micro-CT and implications for plastic surgery

INTRODUCTION

The anatomy of the arterial branches in the upper lip and their relationships to soft tissue are not well described in the literature. The purpose of this study was to explore a method for visualizing the microvessels and soft tissue three-dimensionally to gain better understanding of the upper lip blood supply.

MATERIALS AND METHODS

Seventeen stillborn fetuses were injected with lead oxide-gelatin and stained with iodine. Thirty-four half upper lip specimens were obtained and scanned by micro-computed tomography. The images were then examined and Inveon analysis software was used for three-dimensional reconstructions.

RESULTS

The main supplies to the upper lip were from the superior labial and inferior alar arteries. In some cases, the infraorbital and lateral nasal arteries also branched off to the upper lip. The anatomical variations were classified into six types on the basis of the observed vascular composition patterns. The skin was supplied by the subcutaneous vascular network, formed by the superficial ascending branches of the superior labial and inferior alar arteries. The mucosa was supplied by the submucosal vascular network, formed by the deep ascending branches of the superior labial artery and the labial branches of the infraorbital artery. The muscles were supplied by small vertical branches from the subcutaneous and submucosal vascular networks.

CONCLUSION

This study provides new anatomical insight into the upper lip by describing the microvessels and the relationship between the arteries and the soft tissue involved. This is important information for clinical applications in upper lip plastic surgery.

The Superficial Face Dissection as an Example for Integrating Clinical Approaches, Authentic Learning, and Changing Perspectives in Anatomy Dissection

Hands-on dissection-based learning of anatomy offers an unique and valued experience for medical students. Too often however, the inexperienced student's focus is to avoid damage to unfamiliar structures instead of understanding spatial relationships between structures. This results in unfortunate surrender of a critical learning experience. Additionally, approaches to dissection and anatomic exposure share little alignment to clinical approaches, making it less powerful in clinical applicability. The goal of this viewpoint commentary is based on the experience of the two authors and aims to demonstrate opportunity to introduce clinical approaches for dissection while incorporating relevant anatomical concepts in medical school curriculum that aligns with authentic healthcare practice. Using the dissections of the superficial face as a relevant and current topic of clinical interest, we point out that applying the currently performed dissection approach (medial-to-lateral) falls short of providing sufficient knowledge and understanding of the layered arrangement of facial structures. The lateral-to-medial approach, as performed in surgical face lifting procedures would offer a better understanding of the layers of the face and especially the superficial musculoaponeurotic system (SMAS) accounting for the difficulties of facial dissections on embalmed cadavers. This commentary could offer a potential change in paradigm for students and course facilitators for how to maximize the knowledge transfer during facial dissections. It potentially opens a door to rethink dissection-based learning of anatomy toward techniques and approaches that are aligned to surgical access pathways and thus considered more clinically relevant.

A novel anatomical consideration on the exposed segment of the facial artery

An understanding of the location and depth of the facial artery (FA) is essential in aesthetic surgery and various cosmetic procedures. The purpose of this study was to clarify the three-dimensional (3D) topography of the exposed segment (ES) of the FA and to provide information to help minimize complications during clinical procedures. From 50 embalmed adult cadavers, the undissected and dissected hemifaces were scanned and reconstructed using the 3D scanner. Then the topographic location of the ES was identified and measured from the superimposed the 3D images. The ES was observed in 82% of the whole specimens. The exposure patterns of the ES were examined, and classified into three types: Type I, one site exposed pattern (74%); Type II, two sites exposed pattern (8%); and Type III, nonexposed pattern (18%). The extent of the ES was located at 2.2 mm above and 4.2 mm below the cheilion (Ch)-otobasion inferius line, and 20.0 to 25.2 mm from the Ch on the lateral aspect. In the frontal view, the average distance from the mid-pupillary line to the ES was 7.1 mm, and from the lateral canthal line to the ES was 6.1 mm. The ES was 7.6 mm below the skin surface. The results of this study will help to provide safe guidelines for filler injections as well as selecting the safe regions in various clinical procedures. Clin. Anat. 33:257-264, 2020. © 2019 Wiley Periodicals, Inc.

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.

Anatomical Variations in the Course of Labial Arteries: A Literature Review

BACKGROUND

Nonsurgical lip enhancement using dermal fillers is a very popular procedure. The trend for enlarged lips has been popularized by media and social media. The lips have considerable aesthetic and functional importance, in addition to having a complex anatomy. Serious complications, including vascular compromise or occlusion leading to cutaneous necrosis and blindness, can occur as the result of lip enhancement using dermal fillers. Therefore, aesthetic practitioners require an in-depth understanding of the anatomy and vasculature of the lips and the perioral area prior to providing lip enhancement using dermal fillers.

OBJECTIVES

This literature review aimed to summarize existing data describing the origin, path, and depth of the superior and inferior labial arteries, and to help aesthetic practitioners in providing safer injections to the lips.

METHODS

A literature search was carried out to summarize the available data describing the origin, path, and depth of the labial arteries.

RESULTS

Analysis of the literature revealed that the labial arteries display great variability with respect to path (distribution), presence, and location.

CONCLUSIONS

Increasing the volume of lips through injections of dermal filler needs to be undertaken with caution, and awareness of the anatomical variation in artery location and path is a crucial concept that is essential when injecting the lips.

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.

Unusual branching pattern and termination of facial artery and its clinical implications for facial operations

The facial artery is the main artery of the face and variations in its origin and its branching pattern have been documented. We report herein multiple facial artery branch variations in the face. A large posterior (premasseteric) branch originated from the left facial artery and coursed upwards behind the main trunk of the facial artery. This artery presented with a straight course and was closely related to the anterior border of the masseter. The branch then terminated by supplying the adjacent connective tissue below the parotid duct. It was also observed that the facial artery was very thick and tortuous and terminated as the superior labial artery. Knowledge of this variation is of great clinical significance in facial operations, especially for maxillofacial surgeons and plastic surgeons, because it forms the anatomical basis for the facial artery musculo-mucosal flap.

Surgical anatomy for Asian rhinoplasty

Surgical anatomy is an important and fundamental aspect for all surgical procedures. Anatomy provides a surgeon with the basic and in-depth knowledge that is required and mandatory when performing an operation. Although this subject might be tedious and routine, it is compulsory and should not be overlooked or neglected to avoid any possible postoperative complications. An aggressive and hasty operation without anatomic considerations might cause adverse effects that are irreversible even though a surgical anatomy of the nose is quite simple.