The supraorbital artery emerges from the supraorbital foramen or notch 1 to 3 mm medial to the vertical midpupillary line (Figs. 10 and 11). The artery emerges in contact with the bone and is located lateral to the supratrochlear vasculature. It has a variable course, and can either pierce the corrugator supercilii muscle (medial course) or have no contact with it (lateral course).53 The artery is accompanied by the supraorbital nerve and its vein and becomes more superficial as it pierces the inferior frontal septum, where it gives off a variable number of branches (sometimes larger in diameter) that supply the frontal periosteum.55 This neurovascular bundle has continuous fibrous connections to the periosteum and to the subcutaneous plane. These connections extend three-dimensionally and form the boundaries of the superficial55–57 and the deep forehead compartments.55 After it pierces the frontalis muscle at the level of the middle frontal septum (Figs. 10 and 11), it runs inside the boundaries between the superficial lateral and central forehead compartments. There, the artery gives off a branch that connects to the anterior branch of the superficial temporal artery.
The superficial temporal artery is the most cranial branch of the external carotid artery and emerges from deeper layers into the superficial temporal fascia58 in 100 percent of the observed cases 1 cm anterior and 1 cm superior from the apex of the tragus. Throughout its course in the temporal region, the artery can be identified inside the superficial temporal fascia (layer 3), which is continuous with the midfacial superficial musculoaponeurotic system and the galea aponeurotica of the scalp.59 After crossing the temporal crest, the artery changes planes and can be found in the subcutaneous plane (layer 2) in the forehead (Fig. 12), where it connects with branches of the supraorbital artery. In contrast, the middle zygomaticotemporal vein is identified inside the superficial temporal fat pad (layer 6) and changes planes at the lower temporal compartment and runs deep to the orbicularis oculi muscle (layer 4) toward the forehead, where it is called sentinel vein (Fig. 12).60–62
In the depth of the temporal fossa and in close relationship with the periosteum, the anterior and posterior deep temporal arteries can be identified. When measured to the lateral orbital rim, they have a longitudinal course with 1.5 to 2 cm posterior (lateral) for the anterior deep temporal artery and 2.5 to 3.0 cm for the posterior deep temporal artery (Fig. 13). Performing the deep injection technique in the temple, the proposed “one up and one down” technique (when measured from the point of fusion between the temporal crest and the superior orbital rim) might thus be a good landmark to place the product anterior to the (anterior/posterior) deep temporal arteries (Table 2).63
The facial arterial vasculature varies highly between individuals and even between the left and right sides of the face in the same person. Minimally invasive applications of soft-tissue fillers should thus be performed with care and knowledge to avoid injection-related visual compromise. The latter is considered the worst of all possible outcomes, and its pathophysiology is related to the connection of the vascular territories between the internal and the external carotid arteries with ultimate compromise of the retinal arterial blood flow.
Given the high number of soft-tissue filler injections performed worldwide, the number of severe adverse events remains relatively low. Reasons for this are the constantly developing technology (i.e., introduction of blunt-tip cannulas, antidotes such as hyaluronidase and sodium thiosulfate, injection algorithms, consensus recommendations, and adverse events management centers).
Initially, guidelines for safe injection procedures were developed “eminence-based” but with increasing knowledge and experience transitioned toward “evidence-based.” Increasing interest in facial anatomy contributed significantly to this development, and anatomy is to date a crucial pillar in the daily life of aesthetic providers. Based on the current understanding of the facial arterial anatomy, the two-dimensional and the three-dimensional location of the facial arteries can be predicted, and minimally invasive injections of soft-tissue fillers can be guided accordingly (Table 2).
In the forehead, the arteries transition from supraperiosteal to subcutaneous locations at the middle frontal septum (i.e., between the lower and the upper forehead), identifying the supraperiosteal plane as a safer plane for the placement of soft-tissue fillers (Table 2). In the temple, the anterior branch of the supratrochlear artery runs inside the superficial temporal fascia, designating the subcutaneous fatty layer as a safer layer, whereas the deep injection technique places the product in contact with the bony temporal fossa, deep to the branches of the facial nerve and deep to the superficial temporal artery. Here, the one up and one down technique has been shown to provide aesthetically appealing and safe results (Table 2). The glabella is a high-risk area because of its rich vasculature, which is ultimately connected to the ophthalmic arterial circulation. Safer locations for the application of soft-tissue fillers have been identified to be the supraperiosteal plane, but also intradermally, as here the product is placed superficial to the majority of the arteries (located in the subcutaneous plane) when treating the static glabellar lines (Table 2).
The midface can be separated into a medial and a lateral midface. In the latter, the arteries are located deep but sparing the zygomatic arch and the angle of the mandible. In the latter two locations, injections can be performed in contact with bone (Table 2). In the medial infraorbital area (i.e., tear trough) and in the lateral area (i.e., malar region), applications can be performed deep and in contact with the bone, as here no major arteries can be identified (Table 2). At the dorsum of the nose, the arteries can be easily detected in the subcutaneous plane. Thus, injections deep to the nasalis muscle can be considered a safer location. Similarly, in the nasolabial sulcus, the artery runs in the subcutaneous plane, enabling health care professionals to treat here using the deep approach [i.e., in contact with the bone (canine fossa)] or intradermally if needed.
In the lower face, the arteries are located deep to the platysma, rendering the subcutaneous plane a safer layer. This applies to the upper and lower lips as well, where the safest location seems to be the subcutaneous plane (Table 2). A summary for daily clinical use is provided in Table 2.
Most trepidation associated with soft-tissue filler injections centers on the potential for vascular events. An intimate knowledge of the facial arterial anatomy can help injectors mitigate the risk of such serious circumstances and deliver superior aesthetic outcomes safely.
The imaging part of this study received funding from Q-Med AB, Sweden (grant no. 15092016) and MERZ Pharmaceuticals GmbH (grant no. 13072015). Nirusha Lachman received financial support from the Obaid Vascularized Composite Tissue Award. The authors would like to thank Konstantin Frank, Michael P. Smith, Konstantin C. Koban, and Thilo L. Schenck for support during the data acquisition; the team of the Sectra Visualization Table from Linköping, Sweden, during the data visualization; and the team at Nestlé Skin Health SHIELD, the Chamberlain Group, and BioDigital for the ideation and development of the facial model. Table 2 was generated in collaboration with Jeremy Green, Hassan Galadari, Marina Landau, Tatjana Pavicic, Gabriela Casabona, Sabrina Fabi, Steve Dayan, Andre Braz, Gary Monheit, Torsten Walker, John Rogers, Valeria Lopez, Fabio Ingallina, Carlo Di Gregorio, Giovanni Salti, Jeff Downie, Andreas Nikolis, Stephanie Lam, Luiz Eduardo Avelar, and Alessandra Haddad.
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