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.

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.

Clinical implications of the arterial supplies and their anastomotic territories in the nasolabial region for avoiding arterial complications during soft tissue filler injection.

INTRODUCTION: The nasolabial fold (NLF) causes particular concern during aging in the middle face region. However, arterial complications of filler injections at this site have been continually reported during recent years. The aim of this study was to investigate the arterial locations and their anastomotic pathways related to filler injection sites in the NLF. MATERIALS AND METHODS: Thirty hemi-faces of 15 embalmed Thai cadavers were dissected. Three anatomical landmarks of NLFs were assigned: the inferior margin level (NLF1), the mid-philtral horizontal line level (NLF2), and the inferior alar level (NLF3). Ten hemi-faces of five soft embalmed Thai cadavers underwent a modified Sihler's staining procedure to investigate the arterial anastomoses. RESULTS: The artery closest to all of the landmarks was the facial artery. It was located inferomedial to NLF1 in 28%, and the mean distances along the X- and Y-axes were 3.53 ± 2.11 mm and 3.53 ± 1.75 mm, respectively. It was also located medial to NLF2 in 52.1% with an X-axis distance of 4.93 ± 1.53 mm. Several arteries were located close to NLF3, including the facial (33.3%), lateral nasal (33.3%), and infraorbital (30.0%) arteries. Anastomoses of the nasolabial arteries served to connect both the external-external and internal-external carotid systems. CONCLUSIONS: Several arteries are located close to NLF1-NLF3. To prevent arterial injury, the locations and anastomotic pathways, as possible sources of severe complications, should be recognized prior to NLF filler injection.

Topographic Anatomy of the Infraorbital Artery and Its Clinical Implications for Nasolabial Fold Augmentation.

BACKGROUND: Understanding the topography of the blood vessels distributed around the nasolabial fold region is essential for ensuring the safety of dermal filler injections into the nasolabial fold. The purpose of this study was to provide anatomical information on the infraorbital artery distribution and its relationship with the facial artery for use in clinical procedures involving filler injection during nasolabial fold augmentation. METHODS: The infraorbital artery was investigated in the nasolabial fold region divided into zones I to XII based on clock-hour meridians centered on the infraorbital foramen. The running layers of the infraorbital artery and infraorbital nerve were also compared in the infraorbital foramen. Changes in the infraorbital artery were observed according to vascular dominance of the facial artery. RESULTS: The infraorbital artery was divided into three main branches, palpebral, nasal, and labial infraorbital artery branches in 34.7, 100, and 100 percent of the specimens, respectively; with these branches of palpebral, nasal, and labial infraorbital artery observed most commonly in zones I, V, and VI, respectively. Analysis of the bilateral facial artery topography revealed that its vascular dominance was observed in 19.4 percent. The infraorbital artery was thicker and had a wider distribution on the nondominant side of the facial artery, whereas the nasal infraorbital nerve anastomosed with the facial artery in the lateral nasal region in 57.1 percent. CONCLUSION: Investigating and verifying the vascular structure regarding its interactions with the facial artery and infraorbital artery will provide critical information to physicians performing facial surgery and cosmetic procedures.

The Risk of Skin Necrosis Following Hyaluronic Acid Filler Injection in Patients With a History of Cosmetic Rhinoplasty.

BACKGROUND: As the number of patients using dermal filler for face augmentation increases, the number of adverse events associated with injection may increase. Unpredictable repositioning of blood vessels and a more tenuous blood supply in the operated nose may increase the risk of ischemia, necrosis, and vascular embolism following the filler injection. OBJECTIVES: To highlight the importance of the patient's history of previous cosmetic procedures including rhinoplasty in the emergence of vascular complications. METHODS: Our medical records over a two-year period were reviewed retrospectively to identify all patients who were treated at our center for vascular complications associated with facial hyaluronic acid filler injections. In each case, the subject's demographic data (gender and age), habitual status, past medical and surgical history, the symptoms and clinical presentation at the first visit, the time interval between the injection and the onset of symptoms, injected filler material and brand, injection sites, the introduced treatment, and photographs were reviewed carefully. RESULTS: A total of seven patients were identified, each developing skin necrosis following injection of the hyaluronic acid filler. All patients reported a cosmetic rhinoplasty more than three years ago. CONCLUSIONS: Our finding confirms the conjecture previously made in the literature and suggests that the distinctive vascularity of the nose and the surrounding area may cause filler augmentation induced vascular complications in patients whose vascular circulation has already been compromised by a previous nose surgery.

Sensory recovery of non-innervated free flaps and nasolabial island flaps used for tongue reconstruction of oncological defects.

The aims of this study were to assess sensory recovery and impact on life quality after tongue reconstruction of oncological defects using different flap types. Thirty-two patients who underwent tongue reconstruction for oncological defects 9·3 months after surgery with non-innervated radial forearm free flaps (RFFFs) (N = 16), non-innervated anterolateral thigh free flaps (ALTFFs) (N = 8) and nasolabial island flaps (NLIFs) (N = 8), and 20 age- and gender-matched healthy controls participated in the study. The modalities assessed were cold detection threshold, warm detection threshold (WDT), cold pain threshold, heat pain threshold (HPT), mechanical detection threshold (MDT), mechanical pain threshold (MPT) and the Chinese version of Oral Health Impact Profile-49. ALTFFs was significantly more sensitive than RFFFs (P = 0·005) and NLIFs (P = 0·014) for WDT, and showed a better sensory recovery than RFFFs for HPT (P = 0·011). ALTFFs and NLIFs showed significantly better sensory recovery than RFFFs for MDT (P < 0·005). NLIFs showed the best sensory recovery for MPT, followed by ALTFFs and lastly RFFFs (P = 0·004). NLIFs also showed the least impact on quality of life measures related to psychological discomfort compared to RFFFs and ALTFFs (P < 0·019). All modalities of sensory recovery in RFFFs did not depend on gender and post-operative radiotherapy (P > 0·05). Different flaps for tongue reconstruction of oncological defects appear to have different patterns of sensory recovery and impact on quality of life measures. A longer follow-up period and larger number of participants will be needed in future studies.

Superiorly based nasolabial island flap for reconstruction of the lateral lower eyelid

Background/aim: Various flap procedures have been described and used for the lower eyelids; however, the nasolabial flap is rarely employed. We herein aimed to present the clinical results of using the superiorly based nasolabial island flap for repair of surgical defects extending to the lateral lower eyelid. Materials and methods: Nine patients with a mean age of 62 +- 6 years underwent surgery for reconstruction of the lower eyelid.Results: The diagnosis of lesions was nodular basal-cell carcinoma (n = 5), superficial basal-cell carcinoma (n = 1), well-differentiated squamous-cell carcinoma (n = 1), and basosquamous-cell carcinoma (n = 2). According to the classification reported by Spinelli and Jelks, 6 surgical defects were located at zones II and IV, while 3 were at zones II and V. Five patients required posterior lamellar reconstruction. Lagopthalmos (n = 1), ectropion (n = 1), and transient numbness of the ipsilateral upper lip (n = 1) were noted as postoperative complications. Conclusion: Despite the low number of patients, the present series demonstrated that lower eyelid defects involving zone IV or zone V can be repaired safely and reliably with the superiorly based nasolabial island flap, along with its use shown in the literature for zone II or zone III defects. The technique for raising the flap is fairly simple, with predictable surgical results. In addition, the superiorly based nasolabial island flap provides a reliable means of obtaining good wound healing with acceptable aesthetics, as well as functional results of both the donor site and reconstructed area.

The External Nose: The Nasal Arteries and Their Course in Relation to the Nasolabial Fold and Groove.

BACKGROUND: The blood supply to the external nose is poorly described. The aim of this study was to identify the different types of blood supply to the external nose and the course of the arteries in relation to the nasolabial fold and groove and to the facial muscles. METHODS: With 96 facial halves of 48 adult specimens, the arteries of the outer nose were dissected, and three-dimensional computed tomographic reconstructions and horizontal sections were made. RESULTS: Three main types of blood supply to the external nose were identified, associated with the different types of facial arteries. Moreover, a deep course of the nasal arteries in relation to the nasolabial fold and a very superficial course in relation to the nasolabial groove were found. CONCLUSION: Knowledge regarding the nasal arteries is clinically relevant for filler injection for aesthetic improvements of the nose and nasolabial fold and for planning local flaps in facial reconstructions and also for rhinoplasty.

Choice of recipient vessels for nasal ala reconstruction using a free auricular flap.

Starting in 2010, we experienced seven cases of full-thickness nasal ala defects reconstructed with free auricular flaps. We modified previous methods using retrograde free auricular flaps by including both retrograde and antegrade superficial temporal vessels to enhance the venous drainage of the flap. Based on our experience and the findings of previous reports, we developed an algorithm to insert free auricular flaps for use in nasal ala reconstruction, and to select the recipient vessels. Eight free auricular flaps were transferred in seven cases. In all cases, one artery anastomosis and two venous anastomoses were performed. The facial artery was used as the recipient artery at the nasolabial fold in five cases, and the proximal stump of the superficial temporal artery was used as the recipient vessel via a vein graft in two cases. The facial vein at the nasolabial fold was used in six cases, and the facial vein at the mandible via a vein graft was used in one case. In all cases, the angular vein at the medial canthus was available and used as the second recipient vein. The key to success with free auricular flap transfer for nasal ala reconstruction is to select the proper recipient vessel. We believe that our algorithm and procedure will increase the rate of successful operations.

Aesthetic reconstruction of a superficial defect of the upper lip using a hairy preauricular free flap.

Reconstruction of the upper lip requires symmetrical reconstruction of hairy male skin according to the aesthetic principle. A moderate defect of the upper lip had nonhairy skin on the upper one-third and hairy skin on the lower two-thirds in a Korean man. A hairy preauricular free flap is useful for correcting superficial-thickness skin defects of the upper lip, when local and regional flaps are not applicable. This flap was harvested from hairy posterior sideburn skin of the preauricular area including a vascular pedicle of superficial temporal artery and vein. The superficial temporal artery and vein were anastomosed with the facial artery and vein in the nasolabial fold area. The trapdoor marginal scar of this free flap required marginal scar revision and debulking twice during the postoperative course. A moderate partial-thickness defect of the upper lip in the male patient can be aesthetically restored using this free flap.

Histomorphologic approach for the modiolus with reference to reconstructive and aesthetic surgery.

The modiolus is strongly associated with facial expression, beauty, and aging, and so it is often viewed as the main facial landmark, both functionally and aesthetically. This study examined the modiolus and the surrounding structures histomorphologically with the aim of providing useful information for reconstructive and aesthetic surgery. Nineteen embalmed cadavers (38 hemifaces; 8 males and 11 females; mean age at death, 66.9 years) were examined in this study. For macroscopic observations, the modiolus and facial artery in the perioral region of 28 hemifaces were revealed by meticulous dissection. The modiolus and its surrounding structures were then prepared from 12 hemifaces for routine histology and stained with hematoxylin-eosin and Masson trichrome. A tendinous tissue nodule in the modiolus was found in 21.4% of cases (ie, 6 hemifaces). The facial artery passed approximately 1 mm lateral to the lateral border of the modiolus. In the central region of modiolus, which was an area of convergence of muscle fibers, the tendinous structure appeared as dense irregular collagenous connective tissue. Particularly in the middle layer between the skin and the oral mucosa, it appeared as a dense, compact, and prominent shape horizontally. The finding of the existence of a tendinous structure in the central region of the modiolus, which could act as an anchor for the converging facial muscles, is expected to provide critical information in the field of facial plastic surgery.

Resección quirúrgica de malformación arteriovenosa de alto flujo en ángulo nasogeniano con embolización preoperatoria: reporte de un caso / Surgical resection of high-flow arteriovenous malformation of the nasogenian sulcus with preoperatory embolization: a case report

El 50% de las malformaciones arteriovenosas (MAVs) de alto flujo se ubican en la región craneofacial y pueden producir sangrado con riesgo vital sin diagnóstico y tratamiento adecuado. La resonancia magnética (RM) es útil en el diagnóstico diferencial de las lesiones vasculares, siendo el gold standard la angiografía selectiva. Dado que las MAVs de alto flujo no involucionan espontáneamente, el tratamiento usualmente consiste en embolización con posterior resección quirúrgica. Se presenta un paciente de sexo masculino de 20 años que consulta por aumento de volumen nasogeniano derecho, progresivo, violáceo, blando y pulsátil. Se objetiva mediante RM una zona de vasos serpentiginosos, que se extiende desde el subcutáneo hasta la pared anterior del maxilar. La angiografía cerebral confirma MAV de alto flujo e informa mapeo vascular. Se decide embolización prequirúrgica superselectiva con posterior resección tumoral mediante acceso transvestibular.

The 50 % of arteriovenous malformations (AVMs) of high flow are located in the craniofacial region and can cause life-threatening bleeding without a diagnosis and appropriate treatment. Magnetic resonance imaging is useful in the differential diagnosis of vascular lesions, being the gold standard selective angiography. Since high-flowA VMs do not regress spontaneously, treatment usually involves surgical resection with subsequent embolization. We present a 20 years male patient consulting with a purple, progressive, soft, pulsating enlargement of right-side nasogenian region. Magnetic resonance imaging shows serpiginous vessels, extending from the subcutaneous to the anterior wall of the maxillary. Cerebral angiography confirms high flowAVM and shows vascular mapping. It was decided superselective preoperative embolization with subsequent tumor by transvestibular access.