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

Mapping the localization of the facial artery and vein at the inferior border of the mandible for clinical applications

AIM

To spatially map the position of the facial artery and vein along the inferior border of the mandible based on specific facial reference points.

METHODS

This cross-sectional study included 40 sides of 21 formalin-fixed cadaver heads (11 female, 10 male) with a mean age of 72.92 ± 11.72 years. Superficial dissection was performed to visualize the facial artery and vein at the inferior border of the mandible (FA and FV). Measurements were taken from the FA and FV to various facial landmarks using a digital caliper and medical protractor. Statistical analysis was conducted using Shapiro-Wilk, independent sample t-tests, and paired sample t-tests.

RESULTS

The mean distance between FA and FV was 6.20 ± 2.97 mm. Distances from FA and FV to gnathion, oral commissure, nasal wing, lateral canthus, angle of mandible, intertragic notch, and Manson's point were determined, with no significant differences found between sides and genders (p > 0.05). The closest distances from FA and FV to the line between the intertragic notch and oral commissure were 38.63 ± 4.86 mm and 37.78 ± 5.28 mm, respectively. The angular measurements of FA and FV with inferior border of mandible were 61.45 ± 13.71 and 76.56 ± 10.17 degrees, respectively. The angle between intertragic notch, FA and oral commisure was 102.40 ± 11.12 degrees.

CONCLUSION

The detailed measurements and analysis provided in this study aim to enhance the precision of surgical interventions involving the facial artery and vein. The practical localization methods proposed can assist in minimizing the risk of vascular injuries, improving outcomes in reconstructive and aesthetic procedures.

Patterns of Skin Ischemia After Nasolabial Fold Filler Injection

BACKGROUND

Skin ischemia is a severe complication of nasolabial fold (NLF) hyaluronic acid filler injections. The specific patterns, distribution, and extent of skin necrosis remain poorly understood. The aim of this study is to provide new insights into skin necrosis following NLF injections by analyzing clinical cases and facial anatomy.

METHODS

A retrospective review of patients with skin ischemia after NLF injections was conducted. Computed tomography angiography and anatomical dissections were performed on cadavers to study the facial artery.

RESULTS

Twelve patients with skin ischemia were identified. Three patterns of skin ischemia were observed: Pattern I, NLF+Nose pattern (75%): Skin ischemia affects the nasolabial fold and the entire nose, with the alar, nasal tip, and dorsum being the most affected subunits. Pattern II, NLF+partial nose pattern (16.7%): Skin ischemia involves the nasolabial fold and the lower two-thirds of the nose, primarily affecting the nasal tip and alar, without extending beyond the rhinion. Pattern III, NLF+infraorbital area pattern (8.3%): Skin ischemia is observed in the nasolabial fold and infraorbital region, which may be attributed to the presence of a detoured facial artery. Anatomical studies revealed the course and branches of the facial artery, explaining the distribution of skin ischemia. The skin ischemia may be associated with the perforators of the superficial fat compartments.

CONCLUSION

Skin ischemia following NLF injections can manifest in three distinct patterns, involving various facial regions. Understanding the anatomy of the facial artery and its branches is crucial for preventing and managing this complication.

LEVEL OF EVIDENCE V

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Clinical anatomy of the submental vein

This review provides a comprehensive overview of the anatomy of the submental vein, synthesizing recent findings on its development, anatomical features, course, and clinical significance. Additionally, it introduces the mylohyoid triangle, a new anatomical landmark where the submental vein, submental artery, and the nerve to the mylohyoid muscle run in parallel. As an essential structure in head and neck reconstructive surgery, the submental vein exhibits considerable anatomical variability, primarily due to its complex developmental process. This review highlights the importance of understanding the anatomy of the submental vein and performing thorough preoperative evaluations to enhance surgical success.

Topographic and anatomical variability of the facial artery: Structure and physiology

A large number of complications associated with incorrect visualization of the facial artery or ignorance of the anatomy of the major facial vessel make this problem quite relevant. An in-depth understanding of anatomical variations, projections and topography, taking into account the depth of the facial artery, can help reduce the risk of adverse outcomes during cosmetic procedures. In addition, it assists plastic and maxillofacial surgeons in managing facial trauma and performing surgical procedures, including advanced endoscopic facelift techniques and endoscopic blepharoplasty, where the risk of vascular injury is higher. In cases of vascular injury, anatomical knowledge allows the selection of an optimal hemostatic approach. The aim of this review is to systematize current data on anatomical variations, topography, and external landmarks of the facial artery, providing a classification and visual representation of different patterns. This structured information will undoubtedly benefit clinicians in various fields.

The Depth of the Facial Artery, Meta-analysis

INTRODUCTION

The depth of the facial artery (FA) probably is the most crucial factor while performing aesthetic procedures. The course of FA varies on different levels. The knowledge of exact depth can help physicians to locate the FA more accurately, thereby enhancing the safety of filler injections. This research is the first meta-analysis focused on the quantitative comparison of depth on five different levels of facial artery including angular artery.

MATERIAL AND METHODS

Twelve research papers were included in the meta-analysis. The analyses were performed in five distinctive places: (1) on the horizontal level of cheilion, (2) between oral commissure and nasal alae, (3) on the horizontal level of nasal alae, (4) between nasal alae and medial eye canthus and (5) on the horizontal level of medial eye canthus.

RESULTS

A total of 794, 514, 1095, 414 and 450 arteries were analyzed at the following horizontal levels, respectively: at the level of cheilion, between the nasal alae and oral commissure, at the level of nasal alae, between the nasal alae and medial eye canthus and at the level of medial eye canthus. The final results were as follows: 9.72, 95% CI (6.50-12.94) [mm], 10.34, 95% CI (5.24-15.44) [mm], 9.21, 95% CI (7.05-11.38) [mm], 4.68, 95% CI (4.04-5.31) [mm] and 2.38, 95% CI (1.38-3.38) [mm], respectively.

CONCLUSION

It appears that performing filler injections up to a depth of 4.5 mm, superficially to the facial artery, is considered safe at the level of the oral commissure. The depth between nasal alae and oral commissure varies significantly. A USG exam during the initial consultation prior to any aesthetic procedure might be a reasonable solution in the upper parts of the nasolabial fold.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Validation of Härtel Surface Anatomical Landmarks for Locating the Foramen Ovale: A Computed Tomography Scan Analysis and Revised Technique Description

BACKGROUND AND OBJECTIVES

Härtel triangle provides surface landmarks for locating the foramen ovale (FO) when performing trigeminal nerve percutaneous procedures. Although widely adopted in clinical practice, there is no report that these landmarks have ever been formally validated through modern imaging techniques. Here we aim to validate Härtel anatomical landmarks using computed tomography scans and propose technical considerations for percutaneous trigeminal procedures.

METHODS

Retrospective analysis of 198 FO from 99 adult head computed tomography scans. Measurements included distances from FO to external auditory canal (EAC), FO to midline, eye's midpupillary (MP) line to midline, and eye's inner canthus (IC) line to midline. Statistical analysis was performed, and results were compared with Härtel description.

RESULTS

The mean distance from EAC to FO was 23.26 mm (SD: 3.00 mm). Distance from midline to FO was 25.43 mm overall (SD: 1.87 mm). Distance from midline to MP line was measured at 31.96 mm (SD: 1.89 mm). The mean distance from midline to IC line was 14.68 mm (SD: 1.73 mm).

CONCLUSION

Härtel landmarks can be adjusted for greater accuracy when performing percutaneous trigeminal nerve procedures. The FO is located closer to the EAC and more medially situated than previously assumed. Revised technique suggests aiming the needle trajectory approximately 2 to 2.5 cm anterior to the tragus and targeting a point between the IC and MP lines rather than directly along the MP line. Excessive medial and posterior needle displacement should be avoided to prevent inadvertent vascular injury. These adjustments could enhance procedural accuracy and safety, improving patient outcomes.

The Evaluation of Facial Artery Position in Related to Soft Tissue Pogonion and Soft Tissue Gonion: A Cadaver Study

This anatomic study was designed to assess the position of the facial artery concerning the soft tissue landmarks, pogonion (Pog)and Gonion (Go). Sixty freshly frozen cadavers were used in this study. On the right side, the mean distance between the facial artery and Pog was 7.05±0.66 cm. The mean distance between the facial artery and Go was 3.34±0.36 cm. The results indicated that the facial artery was 32.32%±2.05 of a mandibular length to Go and 67.78%±2.05 Pog. On the left side, the mean distance between the facial artery and Pog was 7.10±0.65 cm. The mean distance between the facial artery and Go was 3.23±0.34 cm. The results indicated that the facial artery was 31.30±2% of the mandibular length at Go and 68.71±2% at Pog. The ratio of the facial artery distance to Pog and Go did not correlate with the mandibular length ( P >0.05). However, the distance between the facial artery, Pog, and Go correlated with mandibular length. ( P <0.001). The ratio of the cross-point of the facial artery with the mandibular border to the length of the mandible about Go and the Pog was generally found to be independent of mandibular length.

The "4.3," A New Filler Lips Technique

BACKGROUND

The "4.3" technique is a hybrid lip augmentation approach that combines the aesthetic benefits of the vertical-lip technique with the fewer entry points of the retrograde linear technique. This method aims to create natural-looking, harmonious, and defined lips using hyaluronic acid (HA)-based fillers, to enhance volume and contour.

AIMS

The objective of this study is to evaluate the effectiveness, safety, and reproducibility of the "4.3" technique in achieving natural lip augmentation with minimal filler volume and reduced injections. This technique is applied to improve the shape and volume of the lips while minimizing the risk of complications.

PATIENTS/METHODS

The technique was applied to male and female patients with standard anatomical features who desired subtle enhancements in lip contour, projection, and volume. The procedure involved four injections in the upper lip and three in the lower lip, using a combination of retrograde linear and vertical techniques. A total of 0.7 mL of HA filler were used for each patient.

RESULTS

The "4.3" technique achieved consistent and aesthetically pleasing results across all patients, with improvements in lip volume, shape, and definition. The reduced number of injections minimized discomfort and risk of vascular complications. The use of Tri-Hyal technology contributed to smooth, plump lips with harmonious proportions.

CONCLUSIONS

The "4.3" technique is a standardized, intuitive, and reproducible method suitable for most patients, regardless of sex. It allows for natural-looking lip augmentation using a reduced volume of filler and fewer injections, making it a safe and effective option for enhancing lip aesthetics.

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 .

Ultrasonographic Evaluation of Facial Artery in the Nasolabial Fold for Gender Differences and Symmetry Between Hemifaces

OBJECTIVES

The aim of this study was to establish the relationship of facial artery with nasolabial fold by color Doppler sonography and to determine facial artery variations and their relationship with age, gender, or hemifaces.

METHODS

The study included 188 patients (94 women, 94 men) aged 18-60 years. Overall, 376 facial arteries in both hemifaces were evaluated for the course within nasolabial fold, symmetry, and relationship with gender.

RESULTS

The mean age of the patients was 39.29 ± 12.81 years. Type A (55.7%) was the most common type in both hemifaces. There was no significant relationship between the course of facial artery and age (P > .05). Asymmetrical course of facial artery was more common in females (54.3%). In both genders, type A was the type with highest symmetry detected.

CONCLUSIONS

Nasolabial fold is one of the important facial regions for filler injection. To prevent vascular injection, course of facial artery should be identified within the nasolabial fold. Type A was the most common type in both hemifaces and genders. Although the rates were close to each other, asymmetry in the course of the facial artery was observed in most of the patients. Ultrasonographic examination which is non-invasive and non-ionizing imaging method can be performed carefully before filler injection to determine vascular tissues.

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.

Morphofunctional and histological patterns of blood vessels in the superficial cervicofacial musculoaponeurotic system in midlateral face regions

OBJECTIVE

The superficial cervicofacial musculoaponeurotic system (SMAS) is a complex network formed by mimic muscles and conjunctive tissue of the superficial fascia of the face.This study aimed to introduce new anatomofunctional data on the importance of the trans-SMAS distribution pattern of the skin microperfusion of the face and to underline the role of SMAS in maintaining the homeostasis of the vascular network that crosses it. Considering the fibrous and muscular matrix of the SMAS, using COLIII and MyoH2 antibodies, together with endothelial immunohistochemistry(IHC)intercellular adhesion molecule 2 marker, we determined the correlation of these structures and their interaction.

METHODS

This study included 33donors of SMAS tissues, which have been stained withregular hematoxylin and eosin (HE), and three different IHC markers have been used (collagen III, muscular tissue, and blood vessels). The samples were collected from parotid, masseteric, jugal, and zygomatic regions. Magnetic resonance angiography was used to identify the main vascular sources of the midlateral regions of the face of another 47 patients.

RESULTS

Significant differences in topographic arrangement, density, and relations of the microsopic vasculature were observed between each of the four regions. Major differences were identified between the role of SMAS in each of these regions, from the parotid capsule to masseteric fascia, transition mobile part, and attaching manners in the zygomatic subunit.

CONCLUSIONS

Blood vessel topography must be related with the surrounding conjunctive and muscular tissue, especially regarding facial SMAS. Intrinsic relations between these three components of the SMAS and nervous fibers can provide us important hints on the functionality of the whole system.

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 roadmap for safety during facial filler injections: A fresh frozen cadaver study

BACKGROUND

Filler injections are commonly applied to reshape facial contouring. However, cadaveric injections of filler for facial contouring on the whole face, followed by anatomic analysis and measurement, have rarely been reported. This study aimed to provide comprehensive anatomical information, including topographies and roadmap of injection point entry, penetration depth, filler location, the hierarchy of facial structure, and vital vascular course.

METHODS

Thirty faces on fresh frozen cadaver heads were used for this anatomic study. The whole face was divided into seven facial zones and 14 injection points for penetration depth measurement and cadaveric injection. Static periosteum injections with a sharp-needle technique were performed. Specimens were then dissected to observe the precise locations of fillers and their relationships with surrounding anatomic structures.

RESULTS

The topography of penetration depth gradually increased from the upper face to the middle face, lower face, and temporal region. Most of the injected hyaluronic acid filler flowed backward to the loose areolar tissue layer between the superficial musculoaponeurotic system and periosteum or deep fascia. Multilevel layer distributions and anastomosis of the vessels were found in the face, especially in the glabella, dorsum nasi, and temporal regions.

CONCLUSIONS

This study can provide clinicians with a comprehensive reference for facial contouring injections: topographies of the injection point and penetration depth and the vascular anatomical structure in high-risk facial zones. The static periosteum injection with effective aspiration is recommended as a relatively safe technique. Clinicians are supposed to grasp the anatomy and injection technique to achieve maximum safety during filler injections.

High-resolution US of the facial vessels with new facial vein landmarks for reconstructive surgery and dermal injection

BACKGROUND

Accurate knowledge of vessel anatomy is essential in facial reconstructive surgery. The technological advances of ultrasound (US) equipment with the introduction of new high-resolution probes improved the evaluation of facial anatomical structures. Our study had these objectives: the primary objective was to identify new surgical landmarks for the facial vein and to verify their precision with US, the secondary objective was to evaluate the potential of high-resolution US examination in the study of both the facial artery and vein.

METHODS

Two radiologists examined a prospective series of adult volunteers with a 22-8 MHz hockey-stick probe. Two predictive lines of the facial artery and vein with respective measurement points were defined. The distance between the facial vein and its predictive line (named mandibular-orbital line) was determined at each measurement point. The distance from the skin and the area of the two vessels were assessed at every established measurement point.

RESULTS

Forty-one volunteers were examined. The median distance of the facial vein from its predictive line did not exceed 2 mm. The facial vein was visible at every measurement point in all volunteers on the right side, and in 40 volunteers on the left. The facial artery was visible at every measurement point in all volunteers on the right and in 37 volunteers on the left.

CONCLUSIONS

The facial vein demonstrated a constant course concerning the mandibular-orbital line, which seems a promising clinical and imaging-based method for its identification. High-resolution US is valuable in studying the facial artery and vein.

RELEVANCE STATEMENT

High-resolution US is valuable for examining facial vessels and can be a useful tool for pre-operative assessment, especially when combined with the mandibular-orbital line, a new promising imaging and clinical technique to identify the facial vein.

KEY POINTS

• High-resolution US is valuable in studying the facial artery and vein. • The facial vein demonstrated a constant course concerning its predictive mandibular-orbital line. • The clinical application of the mandibular-orbital line could help reduce facial surgical and cosmetic procedure complications.

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.

Lingual and Facial Artery Fusion: A Cadaveric Report With Clinical Significance

The external carotid artery (ECA) anterior branches, including the superior thyroid, the lingual, and the facial artery (STA, LA, and FA) present variability among cadaveric studies. These arteries may usually originate as isolated branches from the ECA anterior surface and atypically migrate proximally or distally and/or fused into trunks with the most common fusion that of the LA with the FA, into the linguofacial trunk (LFT), and the rarer ones those of the thyrolingual and thyrolinguofacial trunks. The current report describes a case of a bilateral fusion of the LA with the FA into an LFT and another case of a unilateral origin of the FA from the LA (aberrant FA).  In a 75-year-old donated male cadaver, a bilateral symmetrical LFT coexisted with a right-sided STA origin from the ECA proximal origin, at the level of the common carotid artery (CCA) bifurcation. In an 82-year-old donated female cadaver, at the left side, the atypical origin of the FA from the LA proximal origin coexisted with a common trunk of the left CCA with the brachiocephalic artery, and an atypical origin of the STA from the CCA, 3.65 mm inferior to the CCA bifurcation. This report provides a detailed description of the abnormal origin of the ECA anterior branches, the potential fusion of these branches, their exact location, and the existence of an unusual origin proximal or distal to the CCA bifurcation. Aberrant origin and course remain important in surgical and interventional approaches. A thorough understanding of the typical and variable anatomy of the ECA anterior branches ensures safe and successful intervention. Careful preoperative staging and precise dissection are essential components of this process.

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.

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.

A 3D map of the lingual artery-The perfect tool for transoral robotic surgeries on the base of tongue

BACKGROUND

Knowledge about the anatomy of the lingual artery (LA) is of immense importance when performing procedures on the base of tongue (BOT).

METHODS

A retrospective analysis was performed to establish morphometric data of the LA. The measurements were performed on 55 consecutive patients who underwent head and neck computed tomography angiographies (CTA).

RESULTS

A total of 96 LAs were analyzed. Additionally, a three-dimensional heat map (showing the oropharyngeal region from the lateral, anterior, and superior point of view) of the occurrence of the LA and its branches was created.

CONCLUSION

The length of the main trunk of the LA was measured to be 31.94 ± 11.44 mm. This reported distance is thought to be a surgical safe zone when performing transoral robotic surgery (TORS) on the BOT because it represents the area where the LA does not give off any major branches.

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.

Vasculature of the Nasal Cartilage Region Related to Filler Injection

BACKGROUND

A filler injection in the nose can be essential but is also dangerous, especially in the nasal cartilage region. To safely and accurately perform a filler injection, surgeons must have detailed knowledge of nasal anatomy.

OBJECTIVES

Associated the vessel branches and the characteristics of different nasal regions to provide suggestions for more suitable injection sites.

METHODS

Fifty specimens underwent computed tomography (CT) after contrast infusion. Qualified specimens were selected for 3D CT reconstruction. Dissection was performed to confirm the accuracy of the CT data.

RESULTS

The branches of arteries with large diameters, the dorsal nasal artery (DNA) and the lateral nasal artery (LNA) were distributed within the superficial musculoaponeurotic system layer. The DNA was seen in only 58% of specimens. The artery crossed the midline over the upper lateral cartilage in 16% of specimens. The LNA was a constant branch that traversed the nasal tip. The LNA crossed the midline to the contralateral side in 18% of patients. We divided the nasal cartilage dorsum into two regions for easy handling: the supratip region (STR) and the nasal tip region (NTR). The branches distributed in the STR mostly originated from the DNA (81.6%, 40/49), while those in the NTR mostly originated from the LNA.

CONCLUSIONS

The vasculature of the nasal cartilage region observed in this study is similar to that observed in previous studies. However, we found that the STR was an advantageous area for filler injection. At the same time, we provided suggestions for more suitable injection methods.

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 .

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.

The Facial Vein on Computed Tomographic Angiography: Implications for Plastic Surgery and Filler Injection

BACKGROUND

Knowledge of the anatomy of the facial vein is essential for plastic surgery and filler injection.

OBJECTIVES

The authors sought to investigate the variation and 3-dimensional (3D) course of the facial vein utilizing computed tomographic angiography.

METHODS

The computed tomographic angiography images of 300 facial veins from 150 Asian patients were included in this study. The distance between each anatomical landmark and the facial vein was measured to position the course. The depth of the facial vein beneath the skin and the height of the facial vein above the periosteum were measured at 5 anatomical planes.

RESULTS

The facial vein showed a relatively constant course with a frequency of 7.0% variation. The vertical distance between the medial canthus, midpoint of inferior orbital rim, or external canthus and the facial vein was 10.28 ± 2.17 mm, 6.86 ± 2.02 mm, or 48.82 ± 7.26 mm, respectively. The horizontal distance between medial canthus, nasal alar, or oral commissure and the facial vein was 6.04 ± 1.44 mm, 22.34 ± 3.79 mm, or 32.21 ± 4.84 mm, respectively. The distance between the mandibular angle or oral commissure and the facial vein at the inferior of mandible was 24.99 ± 6.23 mm or 53.04 ± 6.56 mm. The depth of the facial vein beneath the skin and the height of the facial vein above the periosteum varied from the plane of the medial canthus to the plane of the mandible.

CONCLUSIONS

This study revealed the 3D course of the facial vein with reference to anatomical landmarks. Detailed findings of the facial vein will provide a valuable reference for plastic surgery and filler 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.

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.

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.

Three-Dimensional Computed Tomography of the Detoured Facial Artery: Variations and Implications for Nasojugal Groove Correction

BACKGROUND

When performing filler injection procedures to the nasojugal groove, there is the risk of iatrogenic damage to the detoured facial artery.

OBJECTIVE

To determine the 3-dimensional location of the detoured facial artery.

MATERIALS AND METHODS

The branches of the facial arteries from 118 cadaveric hemifaces were scanned using computed tomography and reconstructed using the Mimics software program.

RESULTS

Detoured facial arteries were found in 47 of the 118 hemifaces (39.8%). Two main arterial patterns were identified: in Type I (29 of 47 cases), there were both detoured and nasolabial trunks where the facial artery originated, whereas in Type II (18 of 47 cases), there was only a detoured trunk. The detoured trunk originated 32.0 ± 5.3 mm from the midsagittal line, 5.0 ± 2.8 mm from the occlusion plane, and 5.9 ± 3.5 mm below the skin layer; the inflection of the detoured trunk was located 30.0 ± 5.6 mm laterally, 26.2 ± 4.4 mm superiorly, and 5.7 ± 2.6 mm deep. The meeting point with the inferior orbital rim plane was located 17.1 ± 3.4 mm laterally, 43.4 ± 3.1 mm superiorly, and 2.8 ± 1.7 mm deep.

CONCLUSION

The 3-dimensional location of the detoured facial artery as reported here will help clinicians to avoid iatrogenic damage when they are performing filler injection 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.

Whole-Face Approach with Hyaluronic Acid Fillers

The use of hyaluronic acid fillers in aesthetic medicine has changed over the years and the procedure became one of the most common in the world. Understanding the ageing process of the face and the anatomical interrelationships in the face have dramatically influenced the use of the hyaluronic acid fillers and the assessment of the patient. It was supported by a new technology of products and by the delivery of tools (eg, blunt cannulas), face imaging, and innovative injection techniques. The whole-face approach challenges the practitioner to look at the face as a whole, and the patient to trust and rely on the treatment plan. Over the years, we have understood, that the most important outcome of aesthetic procedures is what does the whole face look like not static but in motion, and how do people read emotions from it. Nowadays, the result changes "the face information" and makes aesthetic procedures more satisfactory. In this manuscript, we reviewed essentials of the current treatment approach including patient's consultations, product selection and injection techniques used in different parts of the face. One size fits none; thus, we provided a general overview of hyaluronic acid fillers used in different indications and presented several treatment approaches to each region of the face.

The Arteries of the Central Forehead: Implications for Facial Plastic Surgery

BACKGROUND

The forehead has substantial importance as an aesthetic unit. The central and supraorbital parts of this area are supplied by the supratrochlear (ST) and supraorbital (SO) arteries as well as the recently defined paracentral (PA) and central arteries.

OBJECTIVES

The authors aimed to assess the morphometry of the vessels of the forehead in the context of plastic surgery and minimally invasive cosmetic procedures.

METHODS

This research included 40 cadavers directed for forensic autopsy and subjected to postmortem computed tomography angiography. In total, 75 hemifaces were examined for the course and location of arteries relative to the bones and surrounding structures.

RESULTS

The arteries were observed as follows: ST in 97.3%, SO in 89.3%, and PA in 44.0%. The PA can be expected in the 13-mm-wide zone starting 2 mm laterally from the midline. The ST should be expected in the 10-mm-wide area extended laterally from the tenth millimeter from the midline, and the SO should be expected in the slightly wider (11 mm) area extending laterally from the 20th millimeter from the midline. For the proximal main trunks of the ST and SO arteries, we observed no overlap between the zones of occurrence, whereas the zones for the PA and ST main proximal trunks did overlap. No distinctive central artery was observed in the midline region of the forehead, but instead a network of small vessels in the midline region was visible.

CONCLUSIONS

The ST is the main and most conservative artery of this region and the PA is the most variable. A unique and detailed anatomical map was created to better understand the vasculature of the forehead area.

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.

Translucent and Ultrasonographic Studies of the Inferior Labial Artery for Improvement of Filler Injection Techniques

Lower lip augmentation by filler injection is an aesthetic procedure essential for achieving a feminine look and to enhance attractiveness. Complications as a result of injury to the inferior labial artery can result in undesirable outcomes.

METHODS

The translucent technique was used to study the origin of the inferior labial artery in 11 cadavers. Ultrasonography of the inferior labial artery was also performed in 20 volunteers, which provided supplemental data to this study, in relation to establishing recommendations for filler injection.

RESULTS

Five different types of inferior labial artery were described. These types were found in various combination patterns. Types 2, 4, and 5 are more vulnerable to arterial injury during filler injection. Ultrasonography revealed a depth of 6 mm and an arterial position at the vermillion border as the dangerous injection plane.

CONCLUSION

The origins and courses of the inferior labial artery are classified into 5 types. These types are often found in combination with each other in different faces, resulting in large anatomical variation between people. Types of combination influence severity of lower lip necrosis when arterial injury occurs. The physician should be aware of these anatomical variations during aesthetic treatments and reconstructive procedures to avoid the dangers of accidental arterial injury.