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Ultrasound Roadmap of the Facial Artery - Why is Ultrasound the Gold Standard for Dermal Fillers

Updated: Mar 28, 2023



Introduction


The number of soft tissue filler injections performed by aesthetic injectors has continued to increase.


In 2018, over 800,000 soft tissue filler injections were performed in the United States.


Dermal filler injections are, however, not without risk.


Blood vessel occlusion remains the most feared and serious of all the complications linked to dermal fillers.


Vascular occlusion is a rare and potentially life-changing consequence of dermal fillers and happens when they are injected into a blood vessel.


An occlusion means a blockage in the blood vessel, starving oxygen to the tissues that the artery normally supplies. The tissue then dies.


Without returning the blood flow, permanent damage and scarring occur as the surrounding tissue attempts to heal.


Not knowing where the blood vessel lies puts you at risk. So let's map my face and see where the journey ends … Read on to find out more.


 
 

What is the facial artery?


The facial artery is one of the main blood supplies to the face. The facial artery (and its continuation as the angular artery) is essential as it supplies oxygen and nutrients to the lips, nose, and eyes. There is one on each side.


For simplicity, I will refer to the facial artery even though it continues as a differently named artery (the angular artery) after it supplies a branch to the upper lip.

 

What does the facial artery look like?


The facial artery resembles a tree with a main trunk and several branches. Its diameter reduces as it runs up the face.





Main branches of the facial artery in the face:


  • Inferior labial artery; supplying the bottom lip

  • Superior labial artery; supplying the upper lip

  • Lateral nasal artery; supplying the lower part of the nose

  • The angular artery; supplies the upper part of the nose.


I will cover the course of arteries supplying blood to the lip in a separate blog.

 

Are all facial arteries the same?


Although everyone has two facial arteries, the facial artery has different patterns, such as:


  • One main trunk (1% - or about 1:100)

  • The trunk takes an entirely different route.

  • Having different branches.

  • Branches going in different directions.


The facial artery can even be different on each side.


These are only variations as blood still supplies everybody's face but takes a different route.

 

Branches of the facial artery in the face



  • Five branches - 3% of people

  • Four branches - 18%

  • Three branches - 34%

  • Two branches - 28%

  • One branch - 14%


In 3% of us, there are no branches at all.


The difficulty is that the facial artery crosses many areas where filler injections are made.


Not knowing exactly how the main trunk leans or branches can make an injection to enhance the features and contour of the face much riskier.

 

Where can the facial artery be felt?


You can best feel the facial artery about a ⅓ of the way along the jawline.


Try for yourself and see how difficult this is!


The artery then crosses to the angle of the mouth. It often cannot be felt as it is buried deep under various muscles, tissue coverings (fascia) and fat.


Two branches from the artery supply the upper and lower lip


It then heads towards the nose and the eye's inner corner.


The two lip branches described are absent in up to 20% (one-quarter) of people.

 

Can't feel the facial artery?


Here are only a few of the problems with not knowing where the facial artery is during filler injections:


  1. It changes in depth.

  2. It varies in direction.

  3. It is wriggly, or

  4. It can be anchored down.


What's more worrying is that the facial artery is usually buried under the skin and is impossible to feel.


The position of everybody's arteries is different - albeit a few millimetres or a centimetre or two.

 

How can injections into a blood vessel be reduced?


Without ultrasound, all injections of dermal fillers are "blind", relying on touch (arteries pulsate), anatomical knowledge or just plain guesswork.


Some controversial and hotly debated ways to reduce the risk have emerged over the years. They are giving false assurances to some.


Here are a few not-so-fail-safe examples that I will cover in another post:


  • Using skin or bony landmarks.

  • Knowing your anatomy.

  • Injecting deep and just above the bone.

  • Aspirating before injecting.

  • Using a cannula rather than a needle.

  • Avoiding high-risk areas such as the glabellar and nose.

  • Listening to the patient (vascular occlusions hurt!)

  • Minimising overfilling with dermal filler.

  • Using a slow injection technique.

 

Injecting filler into the facial artery is not good news


Injections of dermal fillers based on textbook pictures do not reflect the real world. Everybody's face is different, including the pattern of the blood vessels and the face's blood supply.


Feeling the pulses of an artery or injecting just above the bone can give an injector a false sense of security.


When a filler is injected, there is a small possibility that it may enter the bloodstream or press on the artery.

 

What is a "vascular occlusion"?


If a dermal filler is injected into an artery, it can result in a blockage of the vessel, resulting in the death of the tissue it supplies. This process is known as necrosis.


Necrosis results in serious effects such as permanent scarring, which may need drastic measures such as reconstructive plastic surgery.


Vessel blockage is similar to a stroke or heart attack; the quicker it is treated, the better the outcome. But like most things, prevention is better than cure.


 

How often does a vascular occlusion occur?


The exact figures are unknown.


Current literature suggests this happens about once in every 5000 injections. Another recently quoted risk is 1 in every 100,000. So who knows?


Ok, it's rare, but this is little comfort when it happens to you. Plus, many vascular occlusions go under-reported.


About 60% of injectors have experienced at least one vascular occlusion in their careers.


 

Are there treatments for vascular occlusion?


Early recognition and immediate treatment are the most important ways to reduce the risk of permanent damage.


Time saves tissue, similar to the FAST stroke campaign you may have seen on TV.


There is an enzyme called hyaluronidase that can dissolve a filler. But this is only sometimes effective and is not without risk.


The bad news is that if the occlusion affects your sight, full recovery of your vision is unlikely.


 

Why is ultrasound becoming the gold standard in filler injections?


Quite simply, ultrasound provides high-resolution images of the soft tissues, arteries and veins.


Ultrasound is what is used during scanning babies growing in the womb.


The Clarius L20 allows blood vessels (arteries and veins) and tissues to be easily seen.


 

Injecting blind


Although we get away with injecting blind 99.99% of the time, there is always the one (or 1 in 100,000) where it isn't.


 

The facial artery crossing the jawline


This is the best place to feel the artery. After that, it's tricky to feel where the artery goes.


Variation


The position of the artery is fairly consistent.


What filler injection may this affect?


Jawline

Marionette lines


 

The facial artery halfway between the jawline and lip


As the facial artery travels up to the lips, it may give off a branch called the inferior labial artery (which supplies the chin and lower lip).


Variation


The point where the facial artery gives off this branch varies considerably. My inferior labial artery branches off halfway up my chin as the facial artery continues towards the corners of my mouth.



What filler injection may this affect?


  • Lower lips

  • Marionette lines

  • Jaw

  • Chin


 

Inferior labial artery



 

The facial artery at the corner of the mouth


Here the facial artery is anchored under a band emerging from a muscle that is part of the cheek. This anchoring is fairly consistent and is found 1 ½ cm from the angle of the mouth.


Variation


The artery gives off two branches called the superior labial artery, which supplies the upper lip and the lateral nasal artery. Although this happens in 9 people out of 10, this is only sometimes the case.


What filler injection does this affect?


  • Lips

  • Nasolabial fold

  • Upper lip lines


 

Superior labial artery



 

The facial (aka angular) artery in the nasolabial fold


Once the facial artery supplies the upper lip, it becomes the angular artery that travels along the smile lines (known as the nasolabial fold) to the side of the nose.


Variation


This is where things get tricky as the artery can be in front, lie along, or sit just behind the nasolabial. And the artery lies close to the surface of the skin.


In 40% the facial artery lies in front of the smile line

In 20% the facial artery lies behind the smile line

In 40%, it crosses from one side to the other


This is a well-known danger zone for dermal filler injections. It is safer to inject here using a blunt-ended cannula or not at all! And not too superficial!



What filler injection does this affect?


  • Lips

  • Nasolabial folds

  • Upper lip lines



The facial artery above the side of the nose


Here the facial artery is known as the angular artery. I have a great example of one - so I am in the few 25%. There are many variations. See my pictures and video below.


Variation


In 25% - the artery lies on the side of the nose and continues up.

In 25% - the facial artery ends.

In 20% - the angular artery is a branch of an entirely different artery.

In 30% - the artery deviates up the middle of the cheek.




What filler injection does this affect?


  • Nasolabial fold

  • Midface


 

Conclusion


Due to the variation of the route taken by the facial artery, there are no true safe zones when injecting filler, and we should treat all areas with the utmost caution.


Even a quick scan has revealed some interesting variations of the artery in my face.


So why leave dermal fillers to chance and use ultrasound first?

 

Introducing the Clarius L20


The Clarius L20 is regarded as the ultrasound of choice for medical aesthetics. And has just won a prestigious best practice award. The scanner is also FDA-approved.




Made specifically for medical aesthetics, the L20 has high-resolution imaging to


  • Map blood vessels before injecting

  • Guide the depth of injections

  • Visualise the needle in real-time

  • Confirm placement of deep and superficial fillers

  • Reduced the risk of intravascular injections

  • Assess blood flow after an injection

  • Measure skin thickness before microneedling


At Rejuvenate Face, we use the Clarius L20 to ensure your dermal filler is placed at the optimum depth to give you the ideal and safest aesthetic result.


The Clarius ultrasound allows us to see structures in real-time.


And most importantly, the location of blood vessels before we inject.



 

References

Anatomy of the superior and inferior labial arteries revised: an ultrasound investigation and implication for lip volumization.


Cotofana S, Alfertshofer M, Schenck TL, Bertucci V, Beleznay K, Ascher B, Lachmann N, Green JB, Swift A, Frank K. Anatomy of the superior and inferior labial arteries revised: an ultrasound investigation and implication for lip volumization. Aesthetic Surgery Journal. 2020 Dec;40(12):1327-35.


Anatomy of the facial danger zones: maximizing safety during soft-tissue filler injections.


Scheuer III JF, Sieber DA, Pezeshk RA, Campbell CF, Gassman AA, Rohrich RJ. Anatomy of the facial danger zones: maximizing safety during soft-tissue filler injections. Plastic and Reconstructive Surgery. 2017 Jan 1;139(1):50e-8e


The face–a vascular perspective. A literature review. Swiss dental journal.

von Arx T, Tamura K, Yukiya O, Lozanoff S. The face–a vascular perspective. A literature review. Swiss dental journal. 2018 May 1;128(5):382-92.


Arteries of the face and their relevance for minimally invasive facial procedures: an anatomical review.


Cotofana S, Lachman N. Arteries of the face and their relevance for minimally invasive facial procedures: an anatomical review. Plastic and reconstructive surgery. 2019 Feb 1;143(2):416-26.


Ultrasound imaging of facial vascular, neural structures and relevance to aesthetic injections: a pictorial essay.

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The facial artery: A Comprehensive Anatomical Review.

Lee HJ, Won SY, O J, Hu KS, Mun SY, Yang HM, Kim HJ. The facial artery: A Comprehensive Anatomical Review. Clin Anat. 2018 Jan;31(1):99-108. doi: 10.1002/ca.23007. Epub 2017 Nov 16. PMID: 29086435.


Facial artery, an essential anatomy in different specialties: a review.

Constanza AK, Marta AM, Ignacio NC. Facial artery, an essential anatomy in different specialties: a review. J Otolaryngol ENT Res. 2022;14(1):14-20


Topographic anatomy of the superior labial artery for dermal filler injection. Plastic and reconstructive surgery.


Lee SH, Gil YC, Choi YJ, Tansatit T, Kim HJ, Hu KS. Topographic anatomy of the superior labial artery for dermal filler injection. Plastic and reconstructive surgery. 2015 Feb 1;135(2):445-50.


The facial artery: a comprehensive anatomical review. Clinical Anatomy.


Lee HJ, Won SY, O J, Hu KS, Mun SY, Yang HM, Kim HJ. The facial artery: a comprehensive anatomical review. Clinical Anatomy. 2018 Jan;31(1):99-108.

The role of anastomotic vessels in controlling tissue viability and defining tissue necrosis with special reference to complications following injection of hyaluronic acid fillers.


Ashton MW, Taylor GI, Corlett RJ. The role of anastomotic vessels in controlling tissue viability and defining tissue necrosis with special reference to complications following injection of hyaluronic acid fillers. Plast Reconstr Surg. 2018;141(6):818e-830e.


Vision loss associated with hyaluronic acid fillers: a systematic review of the literature.


Kapoor KM, Kapoor P, Heydenrych I, Bertossi D. Vision loss associated with hyaluronic acid fillers: a systematic review of the literature. Aesthetic plastic surgery. 2020 Jun;44(3):929-44.


Global aesthetics consensus: avoidance and management of complications from hyaluronic acid fillers—evidence-and opinion-based review and consensus recommendations.


Signorini M, Liew S, Sundaram H, De Boulle KL, Goodman GJ, Monheit G, Wu Y, De Almeida AR, Swift A, Braz AV, Group GA. Global aesthetics consensus: avoidance and management of complications from hyaluronic acid fillers—evidence-and opinion-based review and consensus recommendations. Plastic and reconstructive surgery. 2016 Jun;137(6):961.

Complications following injection of soft-tissue fillers.

Ozturk CN, Li Y, Tung R, Parker L, Piliang MP, Zins JE. Complications following injection of soft-tissue fillers. Aesthetic surgery journal. 2013 Aug 1;33(6):862-77.


New anatomical insights on the course and branching patterns of the facial artery: clinical implications of injectable treatments to the nasolabial fold and nasojugal groove.


Yang HM, Lee JG, Hu KS, Gil YC, Choi YJ, Lee HK, Kim HJ. New anatomical insights on the course and branching patterns of the facial artery: clinical implications of injectable treatments to the nasolabial fold and nasojugal groove. Plastic and reconstructive surgery. 2014 May 1;133(5):1077-82.


Topography of superficial arteries on the face.


Yang HM, Lee YI, Lee JG, Choi YJ, Lee HJ, Lee SH, Hu KS, Kim HJ. Topography of superficial arteries on the face. Korean Journal of Physical Anthropology. 2013 Dec 1;26(4):131-40.

Anatomical variations in the course of labial arteries: a literature review.


Samizadeh S, Pirayesh A, Bertossi D. Anatomical variations in the course of labial arteries: a literature review. Aesthetic surgery journal. 2019 Oct 15;39(11):1225-35.


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