Anatomy of the Supraorbital Region and the Evaluation of it for the Reconstruction of Facial Defects

Mapping the Vascular and Muscular Topography of the Glabellar Region: Implication for Improving Safety and Efficacy of the Glabellar Injections

BACKGROUND

Botulinum neurotoxin (BoNT) and filler injections into the highly vascularized glabellar region for aesthetical purposes are extremely common. Injections into the glabellar region without precise anatomical knowledge of its vascular and muscular topography may pose the risk of severe complications.

OBJECTIVES

We aimed to improve the safety and efficacy of the glabellar injections by mapping the regional muscles and vasculature in relation to the medial canthus and the defined reference lines.

METHODS

Meticulous dissection was performed to reveal glabellar region muscles and arteries under surgical microscope, in 16 hemifaces of whom arteries are injected with red-dyed latex. Location of the angular artery (AA) along with its branches was noted in relation to glabellar muscles.

RESULTS

The AA was always located superficial to the levator labii superioris alaeque nasi muscle (LLSAN) and then coursed toward the medial canthus to anastomose with the supratrochlear artery deep to the origin of the depressor supercilii (DS). The AA gave subcutaneously located central and paracentral branches coursing close to the mid-face line in 14 out of 16 hemifaces. Variable muscular connections were also present between the LLSAN, the DS and the procerus (P) muscles. No arteries were detected at the base of the medial eyebrow to which the DS, the P, and the frontalis (F) inserted.

CONCLUSIONS

This study provides a detailed map of muscular and vascular anatomy of the glabellar region to facilitate safe and efficient filler and BoNT injections without complications.

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 .

Supraorbital artery: Anatomical variations and neurosurgical applications

Background

The supraorbital artery (SOA) originates from the ophthalmic artery in a superomedial aspect of the orbit, exiting through the supraorbital groove to emerge onto the forehead. The SOA has important neurosurgical considerations regarding different approaches and bypasses. The SOA is poorly described in the standard anatomical textbooks. Therefore, we present this article to describe the anatomical variations of the SOA and their implications on the neurosurgical field.

Methods

We conducted a literature review in PubMed and Google Scholar databases to review the existing literature describing the SOA anatomy and its neurosurgical applications.

Results

While reading the available articles and original works regarding SOA, we identified 22 studies that discuss the SOA. We noticed the anatomical variations of the SOA in terms of origin, course, diameter, branches, depth, and distance in relation to the midline and vertical glabellar line. We also discussed certain applications of SOA and its importance in neurosurgical approaches, bypass, photoplethysmography, aneurysms, and reconstruction of cranial fossa defects.

Conclusion

The variable anatomy of the SOA has a paramount impact on performing different neurosurgical approaches. Therefore, cadaveric studies of the SOA are important to explore potential methods for the preservation of the artery in different neurosurgical applications.

Anatomic Variations of the Lateral Branch of the Supraorbital Nerve Observed in Endoscopic Forehead Surgery

Surgeons dissect carefully in the medial third of the supraorbital rim to preserve the supraorbital nerve (SON) during surgical forehead rejuvenation. However, the anatomic variations of SON exit from the frontal bone have been researched in cadaver or imaging studies. In this study, we report a variation in the lateral branch of SON observed in an endoscopic view during forehead lifts. A retrospective review of 462 patients who underwent endoscopy-assisted forehead lifts between January 2013 and April 2020 was performed. Data, including the location, number, and form of the exit point and thickness of SON and its lateral branch variant, were recorded and reviewed intraoperatively, utilizing high-definition endoscopic assistance. Thirty-nine patients and 51 sides were included, and all patients were female, with a mean age of 44.53 (18-75) years. This nerve exited a foramen in the frontal bone ~8.82 ± 2.79 mm lateral to SON and ~1.89 ± 1.34 mm from the supraorbital margin vertically. Observed thickness variations of the lateral branch of SON included 20 small, 25 medium, and 6 large nerves. This study revealed various positional and morphologic variations of the lateral branch of SON in an endoscopic view. Thus, surgeons can be alerted of the anatomic variations of SON and establish careful dissection during procedures. In addition, the findings of this study will be useful in planning nerve blocks, filler injections, and migraine treatments in the supraorbital region.

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.

Evaluation of Supratrochlear, Supraorbital and Angular Artery Course Variations and Depth by Doppler Ultrasound

BACKGROUND

Supratrochlear (STA), supraorbital (SOA), and dorsal nasal artery (DNA) branches from the ophthalmic artery and angular artery (AA) from the facial artery are the primary suppliers of blood to the upper face. Filler injection without precise knowledge of its vascular topography poses a risk of severe complications.

METHODS

Seventy-four hemifaces from 37 subjects with a median age of 25.0 (21.0, 35.0) years and a median body mass index of 21.2 (20.0, 25.4) kg/m² underwent high-frequency ultrasound tests between March 2022 and April 2022. The bilateral location, depth, peak systolic velocity (PSV), and inner diameter (ID) of the four periorbital arteries (STA, SOA, DNA, AA) were measured.

RESULTS

The average ID ranges from 0.6~1.0 mm, and the average PSV ranges from 9.2~24.9 cm/s. All arteries detected passed through the superficial subcutaneous fascia. Most subjects' STAs traveled within 1.0 to 2.0 cm from the midline (left 96.8%, right 93.8%), while SOAs were mainly concentrated within 2.0 to 4.0 cm (left 83.9%, right 81.3%). STAs were more superficial and had a larger internal ID and PSV than SOAs (p<0.001). Except for the ID of the right SOA2 being significantly larger than that of the left SOA2 (p<0.05), no dominant side was found. The depth of STAs and SOAs was moderately correlated with BMI (p<0.05), except for STA1 on the left side. The course of AAs presented a high variability.

CONCLUSION

These findings emphasize that the periorbital arteries carry with it a likelihood of ocular complication risks during injection. Targeting the supraperiosteal layer in the STA area and the supramuscular layer in the SOA area of the inferior forehead during injection seems reasonable, and an area within 1.0~2.0 cm from the midline should be avoided. Additionally, the high variability of AAs will enhance the understanding of the anatomy of the facial artery terminals.

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 .

Efficacy of Percutaneous Intraarterial Facial/Supratrochlear Arterial Hyaluronidase Injection for Treatment of Vascular Embolism Resulting From Hyaluronic Acid Filler Cosmetic Injection

BACKGROUND

Vascular embolism is a serious complication of hyaluronic acid (HA) filler cosmetic injection, and hyaluronidase injection has been proposed as the treatment. Until now, there has been a lack of adequate clinical evidence regarding the benefits of treatment for HA filler-induced vascular embolism by percutaneous facial or supratrochlear arterial hyaluronidase injection.

OBJECTIVES

The authors sough to evaluate the efficacy of percutaneous facial or supratrochlear arterial hyaluronidase injection as a rescue treatment for HA filler-induced vascular embolism.

METHODS

We included 17 patients with vascular embolism after facial HA filler injection. Intraarterial injection of 1500 units hyaluronidase was performed via facial artery for 13 cases with skin necrosis and via supratrochlear arterial for 4 cases with severe ptosis and skin necrosis but no visual impairment. Simultaneously, general symptomatic treatment and nutritional therapy were performed.

RESULTS

After hyaluronidase injection, facial skin necrosis in all cases was restored and ptosis in the 4 cases was also significantly relieved. Patients were subsequently followed-up for 1 month to 1 year. The skin necrosis in 16 patients completely healed, and only 1 patient had small superficial scars.

CONCLUSIONS

It is effective to alleviate skin necrosis and ptosis resulting from HA filler embolism via percutaneous facial or supratrochlear arterial hyaluronidase injection.

LEVEL OF EVIDENCE: 4

Ultrasonography Analysis of Vessels Around the Forehead Midline

BACKGROUND

Filler injection into the glabella is well known to be a highly dangerous procedure due to the high risk of embolism and intravascular injection. Although it is conventional practice to insert the cannula into the middle of the forehead to perform injections into the glabella or radix, vascular structures can be observed in this region during anatomic dissection procedures.

OBJECTIVES

The aim of this study was to characterize the blood vessels around the forehead midline in order to provide crucial anatomic information for ensuring the safety of noninvasive procedures involving the forehead and glabella.

METHODS

Ultrasonography image scanning was performed at the following 4 points on the forehead midline: trichion (P1), metopion (P2), halfway point between metopion and glabella (P3), and glabella (P4). The courses and locations of vessels were identified and classified according to their proximity to the forehead midline.

RESULTS

Vessels coursing within 0.75 cm either side of the forehead midline were found in 34% to 50% of individuals. Arteries running near the forehead midline tended to be dominant on the right side of the forehead except in the P4 area. About half of the individuals had vessels in the P4 area, of which 96.7% were veins.

CONCLUSIONS

The present results indicate that there are superficial vessels running close to the midline of the forehead. This anatomic information can explain the higher incidence of vascular complications during conventional aesthetic procedures. To ensure safety, the cannula entry point or needle puncture point for glabella augmentation should be reconsidered.

Complications after cosmetic periocular filler: prevention and management

Soft tissue fillers are a mainstay in contemporary, minimally invasive facial rejuvenation procedures owing to timely results and minimal recovery period. Although associated with a low complication rate, soft tissue fillers are not without risk. Complications range from mild superficial skin irregularities to granuloma formation to vascular occlusion leading to skin necrosis or even blindness. Fillers vary in composition, elasticity, hydrophilicity and duration of effect that is tailored to specific cosmetic indications. Selecting the right product for the desired effect can cut down on unwanted outcomes. Severe adverse events can be avoided with safe injection technique, early recognition of symptoms and a thorough knowledge of the local anatomy. This review outlines several complications all providers should recognize and discusses strategies for their prevention and management.

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.

Localization and Topography of the Arteries on the Middle Forehead Region for Eluding Complications Following Forehead Augmentation: Conventional Cadaveric Dissection and Ultrasonography Investigation

Forehead augmentation with filler injection is one of the most dangerous procedures associated with iatrogenic intravascular injection resulting in the severe complications. Nonetheless, few studies have determined the explicit arterial localization and topography related to the facial soft tissues and landmarks. Therefore, this study aimed to determine an arterial distribution and topography on the middle forehead region correlated with facial landmarks to grant an appropriate guideline for enhancing the safety of injection. Nineteen Thai embalmed cadavers were discovered with conventional dissection and 14 Thai healthy volunteers were investigated with ultrasonographic examination on the middle forehead. This study found that at the level of mid-frontal depression point, the transverse distance from the medial canthal vertical line to the superficial and deep branches of supraorbital artery were 9.1 mm and 15.1 mm, respectively. Whereas the depths from the skin of these arteries were 4.1 mm and 4.3 mm, respectively. Furthermore, the frontal branch of superficial temporal artery was detectable in 42.1% as an artery entering the forehead area. At the level of lateral canthal vertical line, the vertical distance of frontal branch was 31.6 mm, and the depth from skin of the artery was 2.7 mm. In conclusion, a proper injection technique could be performed based on an intensive arterial distribution and topography, and ultrasonographic examination before the injection is also suggested in order to restrict the opportunity of severe complications.

A case series: 3-dimensional computed tomographic study of the superior orbital vessels: Superior orbital arcades and their relationships with the supratrochlear artery and supraorbital artery

BACKGROUND

Vascular complications from periorbital intravascular filler injection are major safety concerns.

OBJECTIVE

To thoroughly describe the superior orbital vessels near the orbital rim and propose considerations for upper eyelid and forehead injections.

METHODS

Fifty-one cadaver heads were infused with lead oxide contrast media through the external carotid artery, internal carotid artery, and facial and superficial temporal arteries. Computed tomography (CT) images were obtained after contrast agent injection, and 3-dimensional CT scans were reconstructed by using a validated algorithm.

RESULTS

Eighty-six qualified hemifaces clearly showed the origin, depth, and anastomoses of the superior orbital vessels, which consistently deployed 2 distinctive layers: deep and superficial. Of all hemifaces, 59.3% had deep superior orbital vessels near the orbital rim, including 44.2% with deep superior orbital arcades and 15.1% with deep superior orbital arteries, which originated from the ophthalmic artery. Additionally, 97.7% of the hemifaces had superficial superior orbital arcades, for which 4 origins were identified: ophthalmic artery, superior medial palpebral artery, angular artery, and anastomosis between the angular and ophthalmic arteries.

LIMITATIONS

The arterial depth estimated from 3-dimensional CT needs to be confirmed by standard cadaver dissection.

CONCLUSION

This study elucidated novel arterial systems and proposed considerations for upper eyelid and forehead injections.

The Supratrochlear Artery Revisited: An Anatomic Review in Favor of Modern Cosmetic Applications in the Area

The supratrochlear artery represents a terminal branch of the ophthalmic artery. Cosmetic interventions may traumatize it, resulting in a circulation in the lesion in glabellar region and in the medial aspect of the forehead.

This review article aims to synopsise the existing knowledge of the anatomy of the supratrochlear artery in close correlation with minimally invasive cosmetic procedures in the facial area such as soft-tissue filler injections. Their possible adverse effects and their safe application based on the topographic anatomy were included.

A literature review was performed in PubMed/Medline online medical database.

The superficial course of the supratrochlear artery, as well as the rich, variable anastomotic network that it forms with the supraorbital, angular and dorsal nasal artery raise clinical questions in the case of soft-tissue filler injections in the nasoglabellar and central forehead area. Accidental cannulation of the supratrochlear artery and ultimately, the risk of embolization of the central retinal artery in a retrograde fashion might lead to injury with questionable cosmetic results.

Although the risk of complications from the use of soft tissue fillers is considered rare, once happen, the results could be devastating for the quality of life. Thus, the comprehension of the anatomy of the supratrochlear artery is paramount for the health practitioners.

Anatomical Variations of the Supraorbital and Supratrochlear Nerves: Their Intraorbital Course and Relation to the Supraorbital Margin

Background

This study aimed to describe the topographical anatomy of the supraorbital and supratrochlear nerves. Anatomical variations of both the intraorbital course of the 2 nerves and their relation to the supraorbital margin were analyzed.

Material/Methods

The research material involved 50 isolated adult cadaveric hemi-heads and 25 macerated adult skulls. All studied specimens were of Caucasian origin.

Results

Taking into account the location of the frontal nerve division, 2 main variants of the intraorbital course of the supraorbital and supratrochlear nerves were distinguished. The first variant (variant I, 42%) involved cases in which the supraorbital and supratrochlear nerves branched off from the frontal nerve in the distal half of the length of the orbit. In the second variant (variant II, 58%), the frontal nerve branched into the supraorbital and supratrochlear nerves in the proximal half of the orbit. Variant II was characterized by the presence of a thick supraorbital nerve and a long, tiny supratrochlear nerve. For variant I, 27.8% of the supraorbital nerves were divided into the medial and lateral branch within the orbit, whereas, for variant II, 75% of nerves were divided into the medial and lateral branch within the orbit (before crossing the supraorbital margin). Single passage was observed on the supraorbital margin in 80% of wet specimens and in 78% of orbits examined on the macerated skulls.

Conclusions

Both the intraorbital and extraorbital course of the branches of the supraorbital and supratrochlear nerves were highly diverse. These variations should be taken into account during medical procedures performed within the orbital and frontal regions.

Multiplane Forehead Shortening: Sparing the Frontalis Muscle and Supraorbital Nerve

BACKGROUND

An appropriate forehead-to-face ratio is an important factor contributing to a balanced and attractive face. Conventional methods have been used to correct long forehead, but these methods have drawbacks. The primary objective of this study was to introduce a modified technique with better results.

METHODS

Between March of 2015 and March of 2017, 525 patients with long forehead underwent multiplane forehead shortening with sparing of the frontalis muscle and supraorbital nerve. The operation began with a design indicating the area of skin excision. The sensory nerves were preserved during the skin excision, and the frontalis muscle was not cut. Subgaleal dissection was performed through a small window on the galea. The postoperative assessments included the change in forehead length, sensory changes on the scalp, the presence of a scar, alopecia, and synchronous movement of the flap.

RESULTS

A mean forehead shortening of 2.0 cm (range, 1.1 to 2.8 cm) was observed. Sensory deficits were observed only in the anteromedian scalp, which the supratrochlear nerve innervates. However, sensation recovered to the normal level within 6 months. Scars were barely visible or not visible at all in 85.5 percent of the patients. Postoperative alopecia occurred in only two cases. The synchronous movement of the forehead and scalp was natural in all cases.

CONCLUSION

This modified technique of multiplane forehead shortening with sparing the frontalis muscle and supraorbital nerve provided both cosmetic and functional benefits.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Novel Forehead Augmentation Strategy: Forehead Depression Categorization and Calcium-Hydroxyapatite Filler Delivery after Tumescent Injection

Background

The minimally invasive delivery of soft-tissue calcium hydroxyapatite fillers can ameliorate the appearance of forehead depressions and wrinkles. Forehead augmentations using fillers lead to fewer adverse events and to a faster recovery time than those using surgical procedures. However, many physicians avoid using them due to the risk of pain, intravascular injections, and embolisms that can cause skin necrosis and blindness. Strategy to address these issues includes pain reduction through tumescent solution before filler injection considering the vascular pathway. In addition, the strategy is also safer from embolism.

Methods

The author presents a forehead augmentation technique involving the injection of a tumescent solution for tissue hydrodissection. Not only does this create a pocket of space (TS) for filler placement, it also allows the physician to detect bleeding and prevent vessel compromise It is better to minimize the number of entry-points where no vessel exists. By minimizing the number of entry-points and physical proximity to vessels and nerves during injection, this technique reduces the risks of embolization and bleeding. For optimal, patient-customized results, the author also classifies forehead depressions in 5 different categories, depending on the severity, shape, contour, slope, and quantity of volume deficiency observed.

Results

The author treated 218 patients using the author's forehead augmentations (using one central entry-site after TS test injection). The method was easy to perform and safe from adverse effects such as vascular problem, irregularity, infection, and prolonged swelling.

Conclusion

Using this simple technique, I demonstrate how calcium hydroxyapatite fillers can be injected with little force or dilution, thus preserving its original properties while increasing procedural safety, minimizing pain, restoring convexity, and creating ideal curvatures.

The Paramidline Forehead Flap: A Clinical and Microanatomic Study

BACKGROUND

The traditional paramedian forehead flap (FHF) is an axial flap based on the supratrochlear artery (STA). Doppler examination is often used to ensure inclusion of the STA within the flap. The authors hypothesized that a FHF pedicle design could be simplified to extend from the midline of the glabella to 1.2 cm lateral to the midline without compromising outcomes.

OBJECTIVE

To compare clinical outcomes and vessel densities of 2 FHF designs.

METHODS

Two FHF designs were used to repair fifty nasal defects. One was based on Doppler identification of the STA; the other on clinical measurements from the glabellar midline (with no effort to identify the STA). Clinical outcomes, complication rates, and pedicle vasculature of both groups were compared.

RESULTS

There was no significant difference in flap survival or complication rate. Forehead flaps designed on the paramidline glabella had more arteries within their pedicles than Doppler-based FHFs (p < .05). Small arteries predominated, whereas larger arteries were infrequent in both groups. Size and number of arteries were not related to flap survival.

CONCLUSION

A paramidline FHF has equivalent clinical outcomes as a flap based on the STA. A simple and reproducible design of the FHF using only surface landmarks is described.

Topography of the supraorbital nerve with reference to the lacrimal caruncle: danger zone for direct browplasty

PURPOSE

To elucidate the course of the supraorbital nerve (SON) with reference to the lacrimal caruncle in order to facilitate safer direct browplasty by preventing nerve injury.

METHODS

Thirty-four hemifaces from 18 embalmed Korean cadavers were dissected. A vertical line through the upmost point of the lacrimal caruncle and a horizontal line through the supraorbital margin were used as the horizontal and vertical reference positions, respectively. The course of the SON in the frontal view and the point at which it pierced the overlaying musculature were examined.

RESULTS

The SON divides into a superficial branch and a deep branch just after exiting the orbit. In all cases, the deep SON remains in the subgaleal plane deep to the corrugator and frontalis muscles. The superficial SON travels under the corrugator muscle dividing into three branches (medial, intermediate and lateral) and pierced the frontalis muscle at 19-32 mm above the supraorbital margin. However, in 11 cases (32%) the medial branch of the superficial SON pierced the lower portion of the corrugator muscle at 3.6 mm above the supraorbital margin and ran in front of the muscle along with the vertical line through the upmost point of the lacrimal caruncle.

CONCLUSIONS

One-third of the medial branch of the superficial SON without corrugator muscle protection is vulnerable to iatrogenic injury during direct browplasty. Therefore, the oculofacial surgeon must bring the dissection plane of the forehead tissue more superficially around the vertical line through the upmost point of the lacrimal caruncle in order to avoid nerve injury.

Anthropometric Analysis of Facial Foramina in Korean Population: A Three-Dimensional Computed Tomographic Study

Background

Position of the facial foramina is important for regional block and for various maxillofacial surgical procedures. In this study, we report on anthropometry and morphology of these foramina using three-dimensional computed tomography (3D-CT) data.

Methods

A retrospective review was performed for all patients who have undergone 3D-CT scan of the facial skeleton for reasons other than fracture or deformity of the facial skeleton. Anthropometry of the supraorbital, infraorbital, and mental foramina (SOF, IOF, MF) were described in relation to facial midline, inferior orbital margin, and inferior mandibular margin (FM, IOM, IMM). This data was analyzed according to sex and age. Additionally, infraorbital and mental foramen were classified into 5 positions based on the anatomic relationships to the nearest perpendicular dentition.

Results

The review identified 137 patients meeting study criteria. Supraorbital foramina was more often in the shape of a foramen (62%) than that of a notch (38%). The supraorbital, infraorbital, and mental foramina were located 33.7 mm, 37.1 mm, and 33.7 mm away from the midline. The mean vertical distance between IOF and IOM was 13.4 mm. The mean distance between MF and IMM was 21.0 mm. The IOF and MF most commonly coincided with upper and lower second premolar dentition, respectively. Between the sex, the distance between MF and IMM was significantly higher for males than for female. In a correlation analysis, SOF-FM, IOF-FM and MF-FM values were significantly increased with age, but IOF-IOM values were significantly decreased with age.

Conclusion

In the current study, we have reported anthropometric data concerning facial foramina in the Korean population, using a large-scale data analysis of three-dimensional computed tomography of facial skeletons. The correlations made respect to patient sex and age will provide help to operating surgeons when considering nerve blocks and periosteal dissections around the facial foramina.

Reappraisal of Supraorbital Sensory Nerve Conduction Recordings: Orthodromic and Antidromic Techniques

Objective

To establish a supraorbital nerve sensory conduction recording method and assess its usefulness.

Methods

Thirty-one healthy subjects without a history of trauma or neurological disease were recruited. For the orthodromic procedure, the recording electrode was attached immediately superior to the supraorbital notch. The stimulation electrode was placed on points along the hairline which evoked the largest sensory nerve action potentials (SNAPs). The antidromic sensory response was recorded after switching the recording and stimulating electrodes. The measured parameters were onset latency, peak latency, and baseline to peak amplitude of the SNAPs. The electrophysiological parameters of the bilateral supraorbital nerves were compared. We also recruited two patients who had sensory deficits on one side of their foreheads because of laceration injuries.

Results

The parameters of orthodromically recorded SNAPs were as follows: onset latency 1.21±0.22 ms (range, 0.9–1.6 ms), peak latency 1.54±0.23 ms (range, 1.2–2.2 ms), and baseline to peak amplitude 4.16±1.92 µV (range, 1.4–10 µV). Those of antidromically recorded SNAPs were onset latency 1.31±0.27 ms (range, 0.8–1.7 ms), peak latency 1.62±0.29 ms (range, 1.3–2.2 ms), and baseline to peak amplitude 4.00±1.89 µV (range, 1.5–9.0 µV). There was no statistical difference in onset latency, peak latency, or baseline to peak amplitude between the responses obtained using the orthodromic and antidromic methods, and the parameters also revealed no statistical difference between the supraorbital nerves on both sides.

Conclusion

We have successfully recorded supraorbital SNAPs. This conduction technique could be quite useful in evaluating patients with supraorbital nerve lesions.

A cadaveric feasibility study of the intraorbital cannula injections of hyaluronidase for initial salvation of the ophthalmic artery occlusion

BACKGROUND

Phthisis bulbi may follow cosmetic filler injections. Early attempts to inject hyaluronidase into the orbit after detection of devastating signs and symptoms may potentially mitigate the complications.

METHODS

Cannula routes along the orbital walls were studied. Depths of injections were determined in 30 dry skulls. Deep cannula insertions were carefully performed while avoiding exiting the orbit. Forty-six cadaveric orbits with intravascular latex injection were dissected to determine injection techniques, to verify structures at risk along the routes, and to evaluate substance dispersion.

RESULTS

The limited depths of the superior, lateral, medial, and inferior injection routes were 4.2, 3.8, 3.6, and 2.5 cm respectively, while the orbital width was 3.9 cm. The superior parasagittal injection was effective and rarely tears the superior ophthalmic vein, artery, and the optic nerve. The medial injection should be avoided because it may injure the lacrimal sac, the ophthalmic artery, and the optic nerve. Without limited depth, the lateral injection may damage the lacrimal gland and artery and proceeds to damage the optic nerve. The inferior parasagittal injection tends to exit into the infratemporal fossa but the inferior oblique injection may be safer and effective but more complicate with the depth of 4.2 cm.

CONCLUSION

The superior parasagittal injection is a recommended simple technique with a minimal chance of vascular injury. The inferior oblique injection requires more skill but it may be safer because of the lower position. For safety reasons, depth of each cannula insertion should not exceed the orbital width.

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 BasicScience, 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 http://www.springer.com/00266.

Location of facial foramina and mandibular angle from cone beam computed tomographic scans

PURPOSE

The current study's purpose was to determine morphometric analysis of all facial foramina and mandibular angle relative to surgical landmarks from cone beam computed tomographic scans.

MATERIALS AND METHODS

Three-dimensional computed tomographic scans were reconstructed from data of 100 patients (200 sides) aged between 19 and 76 years. Morphometric measurements of all facial foramina relative to surgical landmarks were taken. Mandibular angle was measured.

RESULTS

There was no statistically significant difference between the left and right sides for all parameters (P > 0.05). Therefore, we found bilateral symmetry in the position of all facial foramina and mandibular angle. However, statistically significant differences were determined in sexes in some of these parameters and mandibular angle.

CONCLUSIONS

The knowledge about locations of facial foramina and mandibular angle is important for performing local nerve block and surgery in the face to avoid the neurovascular structures. This study provides a guideline for locations of facial foramina and mandibular angle, which may help surgeons to understand the nerve location precisely during surgery.

An anatomic basis for treatment of retinal artery occlusions caused by hyaluronic acid injections: a cadaveric study

BACKGROUND

In ophthalmic artery occlusion by hyaluronic acid injection, the globe may get worse by direct intravitreal administration of hyaluronidase. Retrograde cannulation of the ophthalmic artery may have the potential for restoration of retinal perfusion and minimizing the risk of phthisis bulbi. The study investigated the feasibility of cannulation of the ophthalmic artery for retrograde injection.

METHODS

In 10 right orbits of 10 cadavers, cannulation and ink injection of the supraorbital artery in the supraorbital approach were performed under surgical loupe magnification. In 10 left orbits, the medial upper lid was curvedly incised to retrieve the retroseptal ophthalmic artery for cannulation by a transorbital approach. Procedural times were recorded. Diameters of related arteries were bilaterally measured for comparison. Dissections to verify dye distribution were performed.

RESULTS

Cannulation was successfully performed in 100 % and 90 % of the transorbital and the supraorbital approaches, respectively. The transorbital approach was more practical to perform compared with the supraorbital approach due to a trend toward a short procedure time (18.4 ± 3.8 vs. 21.9 ± 5.0 min, p = 0.74). The postseptal ophthalmic artery exhibited a tortious course, easily retrieved and cannulated, with a larger diameter compared to the supraorbital artery (1.25 ± 0.23 vs. 0.84 ± 0.16 mm, p = 0.000).

CONCLUSIONS

The transorbital approach is more practical than the supraorbital approach for retrograde cannulation of the ophthalmic artery. This study provides a reliable access route implication for hyaluronidase injection into the ophthalmic artery to salvage central retinal occlusion following hyaluronic acid injection.

NO LEVEL ASSIGNED

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The Mini Supra-orbital Approach for Cerebral Aneurysm of the Anterior Portion of the Circle of Willis

OBJECTIVES

Various mini-invasive approaches have been developed over the last decade to expose the suprasellar area. The supraorbital approach takes a predominant place in exposing the suprasellar area and the Sylvian fissure.

OPERATIVE TECHNIQUE

Based on our surgical experience, the technique of supraorbital subfrontal approach is described in detail in this article. After an eyebrow incision, a small frontal craniotomy was performed. Indications, advantages and limitations: This mini-invasive approach was indicated for patients with unruptured aneurysm, in patients with aneurysmal SAH without intracranial hypertension, and especially in elderly patients. This minicraniotomy (1) gave quick and direct access to the aneurysm; (2) provided less trauma of the temporal muscle and improved the cosmetic resuilts; and (3) reduced the risk of postoperative epidural hematoma thanks to the small detachment of the dura mater from the vault.

CONCLUSION

We concluded that this limited supraorbital approach gave adequate visualization and allows surgical manipulation within eloquent structures and can be specifically applied in absence of intracranial hypertension.

Supraorbital Artery Island Flap for Periorbital Defects

The forehead skin has the same color and texture as the periorbital region as well as the other parts of the face. The forehead is a local flap donor area for the reconstruction of full-thickness periorbital defects. This report presents eight cases in which full-thickness defects resulting from tumor resection have been repaired with supraorbital artery island flaps. Of eight patients, one was female and the rest were male with a mean age of 72.8 years (range, 64-88 years). Defects were located in the medial canthal region, lateral canthal region, glabella, and lateral part of the orbita. The flaps ranged from 2 x 3 cm to 6 x 7 cm in size. The patients were followed for 7 to 18 months. No complications occurred, except for decreased sensation on the forehead, and trapdoor deformity was seen in one case. The outcome was functionally and aesthetically satisfactory in all cases and all patients were happy with the outcome. The supraorbital artery island flap is a good alternative for the repair of defects around the orbita in that the color and texture of this flap match up with the orbital region and that it is pliable, simple, safe, and sensorial and requires only a single-session procedure.