This article uses excerpts from the chapter of the same name in the Face Anatomy atlas. It is of particular importance for specialists involved in the correction of age-related changes and contouring using fillers. The title “Dangerous triangle of the face” was not chosen by chance; it is in this zone that there are prerequisites of an anatomical and functional nature that can interfere with medical manipulation and cause side effects, including severe ones. Let's look at the topography of this triangle and the reasons for its danger.
Introduction
So, a dangerous triangle of the face. We can describe this zone in this way: the apex of the triangle is located in the glabella area, its legs enclose the nasolabial folds and reach the base, which is located under the lower lip [Fig. 1].
Rice. 1. Dangerous triangle of the face.
The area within this zone is often corrected with filler: just think about glabellar lines, nasal hump correction, nasolabial folds and lip remodeling. The anatomical feature, or originality of this zone, which makes it so “insidious”, lies in its blood supply and especially in the topography of the arteries.
Triangle and arteries
One of the main arteries in this area is the facial artery, a branch of the external carotid artery. The facial artery, immediately after its origin, goes upward and passes to the face in front of the masticatory muscle, where its pulsation can be determined by palpation. Next, it is directed medially and towards the lips, giving off branches - the superior and inferior labial arteries, then passes under the muscle that lifts the upper lip, and reaches the wing of the nose, where its course becomes superficial and ends with two terminal branches - the arteries of the wing of the nose and the angular . Up to this point, everything is clear and clear, but in reality this is not always the case [Fig. 2].
Rice. 2. Facial artery - angular artery.
I will explain more clearly: there are many works with cadavers that emphasize the fact of the existence of frequently encountered anatomical variations and the place of origin of the facial artery, the course of this vessel and its branches. Often such variations are more the norm than the exception. Therefore, it can be argued that even with in-depth knowledge of anatomy, there is a possibility of complications due to the abnormal arrangement of blood vessels. Therefore, it is necessary to use techniques that help to avoid possible side effects as much as possible.
Features of blood supply in the facial area.
Features of blood supply in the facial area.
The maxillofacial area is supplied with blood by the branches of the external carotid artery, which form a group of anterior, middle and posterior branches.
The anterior group includes the thyroid, lingual and facial arteries.
The middle group consists of the ascending pharyngeal artery, superficial temporal and maxillary arteries.
The posterior group is formed by the sternocleidomastoid branch, the occipital artery and the posterior auricular artery.
Branches of the external carotid artery.
1 – superficial temporal artery; 2 – occipital artery;
3 – maxillary artery; 4 – external carotid artery;
5 – ascending pharyngeal artery; 6 – internal carotid artery;
7 – muscle that lifts the scapula; 8 – trapezius muscle;
9 – suprascapular artery; 10 – brachial plexus;
11 – thyrocervical trunk; 12 - common carotid artery;
13 – superior thyroid artery; 14 – lingual artery; 15 – facial artery;
16 – anterior belly of the digastric muscle; 17 – buccal muscle; 18 – middle meningeal artery.
The outflow of venous blood from the organs and tissues of the maxillofacial region is carried out into the internal jugular vein, which receives blood from the facial vein, pterygoid venous plexus, lingual, thyroid and mandibular veins.
Lymph from the head and neck area collects in the jugular lymphatic trunks, which also receives lymph from the mastoid, parotid, submandibular, peripharyngeal and mental regional nodes.
Regulation of blood circulation in the vascular system of the maxillofacial region is carried out by the nervous and humoral pathways. In addition, the vessels have their own basal tone (myogenic regulatory mechanisms).
The vasomotor center of the medulla oblongata sends impulses along nerve fibers through the cervical sympathetic nodes to the vessels of the maxillofacial region.
The vessels of the face form an abundant network with well-developed anastomoses, so wounds on the face heal quickly.
When carrying out all procedures , you should be as careful as possible to avoid intra-arterial and intravenous administration of the drug.
It is safe to inject the drug into the periosteum using cannulas, which are less dangerous than needles.
DANGEROUS AREAS FOR INSTRUCTION OF FILLERS.
Projection of the bony openings of the facial part of the skull.
- supraorbitalis (supraorbital foramen) - the place of exit of the supraorbital SNP - the place of intersection of the upper bony edge of the orbit with a vertical line drawn through the medial edge of the iris. SNP is covered by m. orbicularis oculi, direction of movement - up under m. corrugator and m. frontalis.
- infraorbitalis (infraorbital foramen) – the exit point of the infraorbital SNP – the intersection of a point 1 cm below the lower bony edge of the orbit with a vertical line drawn through the medial edge of the iris. SNP is covered by m. orbicularis oculi and m. levator labii superioris direction of movement is downward and medial.
- mentalis (mental foramen) – the place of exit of the mental SNP – the place of intersection of the mid-height of the lower jaw at the intersection with a vertical line drawn through the medial edge of the iris. SNP is covered by m. depressor labii inferioris, the direction of travel is upward and medial.
Deep injections into the projection of the neurovascular bundles can lead to compression of blood vessels and disruption of blood supply, can be painful and cause changes in skin sensitivity.
The nasal region contains many terminal arteries.
When correcting this area, it is important to take special care, because the terminal branches of the arteries pass there, and the injection of Hyaluronic acid can have catastrophic consequences.
With increasing scientific evidence regarding embolization of small facial arteries following filler injections, nasal procedures should only be performed using cannulas.
From the ophthalmic artery Dorsal nasal artery Vessels of the angle of the nose Lateral nasal artery
From the external carotid artery to the columella artery.
Interbrow area.
When injecting fillers into the glabella area, local necrosis may develop due to the small number of vessels in this area.
In the area delimited by the points of fixation to the bone m. orbicularis oculi from the sides, m. corrugator supercilii above and m. procerus from below, the distribution of the filler is difficult (especially drugs with high viscosity HA), creating a high local pressure of the drug on the tissues and vessels.
Temporal and periorbital regions.
The superficial temporal (sentinel) vein is located in the temporal region behind the artery of the same name and follows its course. Crossing the temporal region 1-1.5 cm above the zygomatic arch, the vein in the layer of subcutaneous fatty tissue is directed to the auricle.
At the medial edge of the orbit, the angular vein is located superficially ; it communicates through the veins of the orbit with the cavernous sinus of the dura mater.
Careless injection of filler into the lumen of the vein or its excessive amount can lead to thrombosis, hematoma or later complications of an infectious nature.
temporales (temporal branch) of the facial nerve in the temporal region lies under the SMAS and goes to the tail of the eyebrow.
The place of its surface occurrence is located in the projection of a triangle, the apex of which is located 2 cm above the end of the eyebrow, and the base is along the lower zygomatic arch.
The parotid salivary gland is in the shape of an inverted triangle with its base on the zygomatic arch and its apex in the area of the angle of the mandible.
The duct of the parotid salivary gland lies below and parallel to the zygomatic arch under the SMAS layer, it horizontally crosses m. masseter and, entering the buccal muscle, appears in the vestibule of the oral cavity.
Damage to the duct leads to the development of chronic local inflammation of the adjacent soft tissues.
transversa facies (transverse artery of the face) is located in the zygomatic region. Parallel and superior to the parotid duct. The vessel supplies blood to the soft tissues of the area, including the skin and subcutaneous tissue through perforator vessels; the permanent perforator is located in the middle of the distance between the wing of the nose and the ear canal or 3 cm medially and 3.5 below the orbital edge.
When performing procedures with a cannula in the zygomatic region, damage to the permanent perforator should be avoided. transversa facies.
marginalis mandibulae (marginal branch of the mandible) of the facial nerve is located under the SMAS and descends first behind the branch and angle of the mandible and, not reaching the posterior edge of the m. depressor anguli oris, extends onto the face, located at this point on the bone.
Deep bone injections in this area should be carried out with caution, because this branch innervates the muscles of the lower lip and part of the subcutaneous muscle of the neck.
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Possible side effects
Basically, complications arise not so much due to rupture of a venous vessel, but due to interruption of arterial blood flow due to compression or when the drug is administered into the lumen of the vessel with subsequent embolization of the terminal branches with small fragments [Fig. 3].
Rice. 3. Reasons for the development of skin necrosis. Intravasal injection (top), vessel compression (bottom).
What could happen next? Stopping arterial flow leads to necrosis and tissue death in the blood supply zone of a given vessel. Cases of necrosis of the skin of the wing and tip of the nose, lip tissue and glabella area have been described [Fig. 4–5].
Rice. 4. Necrosis of the tip or wing of the nose.
Rice. 5. Zones of necrosis.
An even more serious risk factor is associated with the fact that the facial artery represents the communication between the external and internal carotid arteries. Its terminal branch, the angular artery, anastomoses with the ophthalmic artery, a branch of the internal carotid artery. It is this connection between the vessels that can lead to embolization of the ophthalmic artery with small fragments of filler and further penetration into the central retinal artery with a possible decrease in vision up to blindness [Fig. 6–7].
Rice. 6. Iatrogenic retinal artery occlusion caused by the injection of fillers.
Rice. 7. Microembolism of the ophthalmic artery: etiopathogenesis.
Treatment methods at the Innovative Vascular Center
The vascular surgeons of our clinic have significant experience in unique operations on the carotid arteries with pathological tortuosity. The main problem for surgical treatment is determining clear indications for surgical treatment. Our clinic has developed a clear diagnostic protocol that allows us to determine the clinical significance of a particular tortuosity and the degree of its effect on cerebral blood flow. The experience of successful operations in our clinic for pathological tortuosity exceeds 200 cases.
Therapeutic strategies to prevent and manage complications
It is obvious that it is necessary to use techniques that minimize the risk of developing these dangerous complications. The text of the atlas describes, area by area, all the precautions and manipulations that must be taken to reduce this risk: the use of a cannula, the depth of injection, the quantity and quality of filler injected, and so on. Pallor of the skin and patient complaints of sudden pain in the injection area are signs that blood flow has stopped in this area. We must be able to control this situation.
All measures are aimed at restoring blood flow: urgent dissolution of the filler (if hyaluronic acid was used), warm compresses, massage, etc. Then there are prescriptions that need to be followed at home: antibiotic therapy to prevent bacterial superinfection, antiplatelet agents, topical medications.
In the introduction to the atlas I placed the inscription
“Only non-practitioners do not make mistakes; only through practice does it become possible to reduce the risk of error.”
If all measures are carried out on time and correctly, the spread of the necrosis zone will be minimal, a large area of skin will be preserved and, therefore, the chance of restitutio ad integrum will be higher.
