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Case 3.17
Published in Monica Fawzy, Plastic Surgery Vivas for the FRCS(Plast), 2023
This is from the facial and ophthalmic arteries:The most important source artery is the facial artery – with its superior labial artery, and angular artery branches.The superior labial artery gives off a columellar branch in 2/3 of people, which is sacrificed in an open tip rhinoplasty, leaving the lateral nasal artery, which is a branch of the angular artery to supply the tip. This may be unilateral or bilateral, and lies 2 mm above the alar groove, so injury from an alar base resection during a concomitant open rhinoplasty may lead to tip necrosis.The ophthalmic artery supplies the upper third – with branches such as the anterior ethmoidal artery, dorsal nasal artery, and external nasal artery.
Adapting Injection Techniques to Different Regions
Published in Yates Yen-Yu Chao, Sebastian Cotofana, Anand V Chytra, Nicholas Moellhoff, Zeenit Sheikh, Adapting Dermal Fillers in Clinical Practice, 2022
Yates Yen-Yu Chao, Sebastian Cotofana, Nicholas Moellhoff
The plane of choice for both needle and cannula injections is the deep supraperiosteal or supraperichondral plane. This plane is in the midline of the nose and is mainly avascular, as the majority of vessels travel within the superficial (subdermal) fatty layer. An exception to this generalization is, however, the nasal tip and the root of the nose. At the nasal tip, no layered arrangement can be identified and the columellar, alar, septal, and sometimes the subnasal arteries form an arterial vascular network. Here caution is recommended as the local injection of soft tissue filler can cause compression of the vascular supply. At the root of the nose, the dorsal nasal artery can be identified either superficial or deep to the procerus muscle that increases the risk for intra-arterial product application even in the deep plane. Product applications should also be limited to the midline as at the lateral aspect of the nose, the lateral nasal artery connects to the terminal branch of the anterior ethmoidal artery in the deep plane. Here the deep plane again poses a risk for intra-arterial product application.
Combination Approaches: Using Fillers With Toxins and Energy-Based Devices
Published in Neil S. Sadick, Illustrated Manual of Injectable Fillers, 2020
Filler can also be an effective nonsurgical option in the midface to reshape the nose. Safe execution of filler rhinoplasty, however, is dependent upon a detailed understanding of nasal anatomy. The rich plexus of the vessels in this area makes it particularly vulnerable to vascular injury (74). The nasal dorsum is supplied in part by the dorsal nasal artery, a branch of the ophthalmic artery (75). High injection pressure can lead to retrograde migration of filler into the ophthalmic artery resulting in catastrophic outcomes (76). An additional anatomical consideration includes the quality of nasal skin: the skin is often thinner and more flexible proximally, while thicker toward the nasal tip (77). Because of the sensitive nature of this region, reversible filler may be preferred by less experienced injectors, while stimulatory agents can be used by those with more comfort, although not advisable.
Complications associated with infraorbital filler injection
Published in Journal of Cosmetic and Laser Therapy, 2020
Shivani Reddy, Tuyet A. Nguyen, Nima Gharavi
Notable vasculature in this region include the infraorbital artery, angular artery, dorsal nasal artery, and zygomaticofacial artery (Figure 1). The infraorbital foramen, from which the infraorbital artery and nerve exit, is typically located medially 1/3 of the distance between the medial and lateral canthi, and on average between 6.3–10.9 mm below the infraorbital rim and is not reported to change significantly with age (6,7). The angular artery, a branch of the facial artery, courses along the medial periorbital area and anastomoses with the dorsal nasal artery here (6). This artery can have variations in location, and in some may be located more superficially in the subcutaneous tissue. The zygomaticofacial artery and nerve arise from a foramen at the lateral orbital rim about 0.5–1.0 cm below the horizontal line at the lateral canthus (8).
Specific complications associated with non-surgical rhinoplasty
Published in Journal of Cosmetic and Laser Therapy, 2020
Tuyet A. Nguyen, Shivani Reddy, Nima Gharavi
Although rare, cases of vision loss secondary to filler injection have been reported. Autologous fat injection is most commonly associated with this complication, likely due to the fact that fat injection is often performed under general anesthesia (at the time of liposuction), which prevents the patient from reporting any discomfort. However, all commonly used fillers have been associated with reports of embolic events (14). In a literature review by Ozturk et al., the glabella was the most common site associated with visual disturbances at 50%, followed closely by the nose at 33.3% (9). Injection of filler for non-surgical rhinoplasty poses a specific risk for this complication due to the course of the dorsal nasal artery over the nasal root (15). The dorsal nasal artery is a distal branch of the ophthalmic artery (4). Intravascular injection into the dorsal nasal artery can cause embolization of filler material in a retrograde manner causing occlusion of the ophthalmic arteries and subsequent vision loss. Clinically, this is characterized by instantaneous vision loss and excruciating ocular pain (14). Treatment and reversal of this complication are rarely successful.
Ocular and cerebral infarction from periocular filler injection
Published in Orbit, 2019
Zubair A. Ansari, Catherine J. Choi, Andrew J. Rong, Benjamin P. Erickson, David T. Tse
Filler-related cerebral infarctions have uncommonly been reported in the literature.2,5–13 Most reports detail cerebral infarcts from facial injections of autologous fat,2,6,8–11,13 with few reports from hyaluronic acid5,6,12 or polylactic acid injections.7 Like in our case, the glabella2,6,8,11,12 was the most commonly reported injection site that caused combined ophthalmic and cerebral complications, followed by injections to the nasolabial fold.9,13 In order to understand how certain facial regions could infarct areas of the cerebrum requires a thorough understanding of the neurovascular anatomy of the periorbita. As the external photographs and patient’s history indicate, hyaluronic acid filler was injected to contour the glabella and reduce forehead rhytids. The vascular structures at highest risk for cannulation during glabellar injections are the supratrochlear and supraorbital arteries, both of which supply the superomedial aspects of the forehead. Filler substance was then injected with sufficient force and magnitude to overcome the mean systemic arterial pressures and traveled in a retrograde fashion into the cerebral circulation via the Circle of Willis. From here, it is reasonable to assume that the filler dispersed through both the anterior and middle cerebral arteries, dispersing throughout the right parietal lobe to produce the scattered infarcts seen on MRI. The filler that did not enter the cerebral circulation, now flowing anterograde, entered the ophthalmic artery, which is the first branch of the carotid caudal to the siphon. OCT demonstrates profound loss of both the inner and outer layers of the retina, supplied by the central retinal artery and choroidal vasculature, respectively. Given the skin necrosis at the nasal tip, it can be assumed that the dorsal nasal artery – a branch of the ophthalmic artery that supplies this distribution – was involved as well.