2017-18 HSC Section 4 Green Book

Volume 139, Number 1 • Anatomy of the Facial Danger Zones

CONCLUSIONS Facial filler injections continue to grow in popularity given the limited recovery time and the immediate results. However, their complications can be even more impressive than their aesthetic results. Therefore, we have reviewed the pertinent anatomy in the six danger zones of the face so that practitioners can tailor their injection techniques to maximize safety. Despite detailed published descriptions of the facial vasculature, the anatomy can be quite variable, and vascular injuries can occur even after the best precautions are taken. Likewise, actual needle depth can be difficult to track and at times unpredictable. Most importantly, practitioners need to recognize complications in a timely manner and take the appropriate measures to minimize what can be a devastating result. Rod J. Rohrich, M.D. 9101 North Central Expressway Suite 600 Dallas, Texas 75231 rod.rohrich@dpsi.org references 1. American Society for Aesthetic Plastic Surgery. Aesthetic sur- gery national data bank statistics 2014. Available at: http:// www.surgery.org/sites/default/files/2014-Stats.pdf. Accessed October 18, 2016. 2. Kleintjes WG. Forehead anatomy: Arterial variations and venous link of the midline forehead flap. J Plast Reconstr Aesthet Surg . 2007;60:593–606. 3. Shumrick KA, Smith TL. The anatomic basis for the design of forehead flaps in nasal reconstruction. Arch Otolaryngol Head Neck Surg . 1992;118:373–379. 4. Webster RC, Gaunt JM, Hamdan US, Fuleihan NS, Giandello PR, Smith RC. Supraorbital and supratrochlear notches and foramina: Anatomical variations and surgical relevance. Laryngoscope 1986;96:311–315. 5. Ugur MB, Savranlar A, Uzun L, Küçüker H, Cinar F. A reliable surface landmark for localizing supratrochlear artery: Medial canthus. Otolaryngol Head Neck Surg . 2008;138:162–165. 6. Vural E, Batay F, Key JM. Glabellar frown lines as a reliable landmark for the supratrochlear artery. Otolaryngol Head Neck Surg . 2000;123:543–546. 7. Erdogmus S, Govsa F. Anatomy of the supraorbital region and the evaluation of it for the reconstruction of facial defects. J Craniofac Surg . 2007;18:104–112. 8. Carruthers JD, Fagien S, Rohrich RJ, Weinkle S, Carruthers A. Blindness caused by cosmetic filler injection: A review of cause and therapy. Plast Reconstr Surg . 2014;134:1197–1201. 9. Ozturk CN, Li Y, Tung R, Parker L, Piliang MP, Zins JE. Complications following injection of soft-tissue fillers. Aesthet Surg J . 2013;33:862–877. 10. Li X, Du L, Lu JJ. A novel hypothesis of visual loss sec- ondary to cosmetic facial filler injection. Ann Plast Surg . 2015;75:258–260. 11. Park SW, Woo SJ, Park KH, Huh JW, Jung C, Kwon OK. Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections. Am J Ophthalmol . 2012;154:653–662.e1.

in the subcutaneous plane. 51 There is sparse vas- culature within the areolar layer beneath the muscular layer aside from what they termed the “deep” or “lateral nasal veins” running cephalic to the lateral crura. 51 Saban et al. described a “marginal artery” coursing over the lower lat- eral cartilage caudal border toward the tip after branching from either the facial artery or the lateral nasal artery. 50 The dorsal nasal artery (a terminal branch of the ophthalmic artery) emerges from the medial obit and courses over the dorsum above the muscular layer to contrib- ute to the subdermal plexus at the tip. 51 Maximizing Safety Given the shallow nature of the vasculature located within the nose, a misplaced injection can lead to disastrous results. Superficial injections compressing or injuring the superficial vascula- ture in the tip and alar facial groove can lead to tip and alar necrosis, respectively. Likewise, given the tip, dorsal, and sidewall vessel anastomoses with the ophthalmic artery, intravascular injections in these areas can cause retrograde propagation of filler, leading to ocular ischemia and blindness. Therefore, all lateral injections should be greater than 3 mm above the alar groove and deep. Injec- tions to the tip and dorsum should be deep in the preperichondrial and preperiosteal planes. In several reviews analyzing facial danger zones, nasal filler injections were documented as the leading cause of tissue necrosis and the second leading cause of visual loss after the glabella. 9,10 Fig. 7. The facial artery ( a ) ramifies the inferior alar branch ( b ) and the lateral nasal artery ( d ) before becoming the angular artery ( c ). The dorsal nasal artery ( f ), lateral nasal arteries ( d ), and columellar artery (not pictured) form a rich vascular network at the nasal tip in the subdermal layer ( e ).

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