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Surface landmark of the facial vein for the dermal fillers injection
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 27 (2015) 645–649
Contents lists available at ScienceDirect
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology journal homepage: www.elsevier.com/locate/jomsmp
Original Research
Surface landmark of the facial vein for the dermal fillers injection Dawinee Chinnawong ∗,1 , Tanvaa Tansatit 1 , Piyaporn Phanchart 1 , Natthida Rachkaew 1 The Chula Soft Cadaver Surgical Training Center and Department of Anatomy, Faculty of Medicine, Chulalongkorn University and the King Chulalongkorn Memorial Hospital, 1873 Rama 4 Road, Pathumwan, Bangkok 10330 Thailand
a r t i c l e
i n f o
Article history: Received 17 March 2014 Received in revised form 3 October 2014 Accepted 19 January 2015 Available online 26 February 2015 Keywords: Facial vein Soft tissue landmarks Dermal fillers injection
a b s t r a c t Objective: The purpose of this study was to describe the course of the facial vein and identification of surface landmark of the facial vein for dermal fillers injections. Methods: Thirty flaps of hemiface were turned over to measure the distance between the facial vein and ala of the nose and oral commissure. The vertical distance was measured from the inferior orbital rim to the facial vein. The diameter of the facial vein and the depth from skin surface to the facial vein were measured. Anatomical relationships of the facial vein to its surrounding structure were observed. Results: The course of the facial vein is a large curved course without tortious from the medial canthal tendon downward along the medial orbital rim. The mean vertical distance from the facial vein to the inferior orbital rim was 6.87 ± 1.14 mm. The average horizontal distance from the facial vein to ala of nose was 21.57 ± 3.95 mm. The average horizontal distance from the facial vein to oral commissure was 27.55 ± 3.97 mm. The average depth values from skin surface to the facial vein at the level of ala of nose and oral commissure were 14.44 ± 2.90 and 15.38 ± 2.40 mm, respectively. Conclusions: The course of the facial vein at the level of ala of nose and the oral commissure were approximately 2 and 3 cm, respectively at the depth of 1.5 cm. © 2015 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽
1. Introduction An aging face is a multifactorial process with anatomic, biochemical, and genetic elements. Many exogenous and endogenous factors such as solar exposure, cigarette smoking, medications, alcohol use, body mass index, and endocrinologics status have been implicated as factors that accelerate the facial aging process [1]. In recent years, the number of cosmetic dermatology procedures performed has increased. There are several types of treatment to help combat an aging face such as surgery, botulinum toxin and dermal fillers injection. Among these techniques, the dermal fillers injection is the most commonly used for aging face treatment. Dermal fillers involve filling the wrinkle or crease by the injection of an appropriate filler substances. There are many different types such
夽 Asian AOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asian Society of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathology; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japanese Society of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants. ∗ Corresponding author. Tel.: +66 0899821440; fax: +66 2 2527028. E-mail address: Dew [email protected] (D. Chinnawong). 1 Tel.: +66 0818094414; fax: +66 2 2527028.
as fat, collagen (bovine, human, and purified porcine), hyaluronic acids (HAs), calcium hydroxylapatite (CaHA), and injectable medical devices such as poly-l-lactic acid (PLLA) microspheres [2,3]. The ideal fillers injectable for an aging face should be safe, stable at the implantation site, painless to inject, and minimal complication [4,5]. Complication of dermal fillers injection can be varied and include bleeding, allergic reactions, lower eyelid swelling, and facial vein thrombophlebitis after infection. More serious complications can range from anaphylactic reaction, skin and tissue necrosis, blindness and death [5–9]. It is important for dermatologists to be well informed on the position of anatomical structures beneath the skin at the site of injection. This is because during a filler procedure the needle may come in contact with structures beneath the skin, specifically the facial vein, potentially resulting in venous occlusion [10]. That is often delayed, and presents as a dull pain with bluish discoloration that may simulate a bruise. Therefore, the accuracy knowledge of surface landmarks of the facial vein may help reduce the serious complication that can occur as a consequence of this procedure. The purpose of this study was to describe the course of the facial vein along with accuracy surface landmarks to ultimately allow identification of appropriate dermal filler injection sites.
http://dx.doi.org/10.1016/j.ajoms.2015.01.015 2212-5558/© 2015 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽
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D. Chinnawong et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 27 (2015) 645–649
2. Materials and methods Dissection was performed on 30 hemi-face specimens of soft embalmed cadavers, from Chula Soft Cadaver Surgical Training Center of King Chulalongkorn Memorial Hospital. Selection criteria required specimens with no history of trauma or surgical procedure on the face. All cadavers were donated to the institute for medical education and research was carried out with the written consent of the family delegate. 2.1. Dissection of the cadavers Firstly, a skin incision was made on the forehead roughly 2 cm above the eyebrows and continued around the temporal region, anterior to the external ear canal, to the mandibular angle of the jaw line on both sides and along the mandibular border to the midline. All skin and subcutaneous tissue was removed by lifting from underneath the periosteal layer using a periosteal elevator or a surgical blade. The origin and insertion of the temporalis and the masseter muscles were cut to allow removal. An incision was made around the alveolar bone to detach the facial muscle from the maxilla and mandible. For each orbit, the orbital septum was severed from its attachment on the orbital rim. The periorbital was deflected from the orbital rim and continued toward the optic canal and orbital fissure. The optic nerves and additional structures were cut to remove the contents of both orbital cavities. The nasal cartilage was cut and removed as deep as possible to keep the nose intact, and lifted away along the mucosa of the lateral walls of the maxilla along with the head of the inferior turbinate. This allowed the facial flap to be removed en bloc with the facial musculature and innervations still intact. The facial flap was turned over to allow examination to be performed from a periosteal view. 2.2. Observation and measurement
Fig. 1. The facial vein (red arrow) ran beneath the levator labii superioris (LLS) muscle and the zygomaticus minor (Zm) muscle and crossed over the zygomaticus major (ZM) muscle, while running between the branches of buccal branch (green arrow) of the facial nerve. The facial vein ran under the parotid duct (P) and buccinator muscle (B) along the anterior border of the masseter muscle (M). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
Following attainment of the facial flap, the buccal fat pad was removed to allow identification of the facial vein situated beneath the parotid duct. We observed the course of the facial vein from the anterior border of masseter muscle to the medial canthal ligament (Fig. 1). The horizontal distances between the facial vein and ala of nose and oral commissure were measured using calipers. The vertical distance from the inferior orbital rim to the facial vein was also measured. The diameter of the facial vein and the depth from the surface of the skin were measured at the level of ala of nose and oral commissure (Fig. 2). Additionally, the anatomical relationship between the facial vein and the surrounding structures was observed. At the lower border of the mandible two anatomical landmarks were defined: the anterior palpable border of the masseter and its anterior recess at the inferior mandibular margin. We divided the relationship of the facial vein with the insertion of the masseter muscle into 3 patterns as follows: Type 1, the facial vein was situated lateral to the anterior border of the insertion of the masseter muscle. Type 2, it crossed the mandibular margin medial to the anterior recess. Type 3, it ran between the anterior recess and the anterior border.
The facial vein coursed between the origin of the levator labii superioris muscle and (under) the medial band of the orbicularis oculi muscle just medial to the malar eminence. It ran along the medial orbital rim above the infraorbital foramen for a short distance where it deviated and descended downward before it reached the origin of the masseter muscle. In every specimen the facial vein lied superficial to the sublevator space as well as superficial to all four descending branch of the infraorbital nerve up to the ala of nose and upper lip. At the level of ala of nose, the average horizontal distance from the facial vein to ala of nose was 21.57 ± 3.95 mm. The mean diameter of the facial vein was 2.44 ± 0.72 mm. The average depth from the skin surface to the facial vein was 14.44 ± 2.90 mm (Fig. 1).
3. Results
3.3. Level of the masticator space
3.1. Level of the medial canthal ligament
At the level of the masticator space the facial vein descended obliquely along the medial border of the buccal fat pad and the masseter muscle. In this area the facial vein was usually found accompanying the middle or the lower trunk of the buccal branch of the facial nerve. The superior labial vein running from the medial side drained into the facial vein. It reached the genu of the parotid duct while the parotid duct looped around the masseter muscle to enter the buccinator muscle. The facial vein lied under the insertion
The facial vein crossed over the medial canthal ligament together with a few branches of the angular nerve from the upper buccal branch of the facial nerve. At the medial canthal ligament, the facial vein was covered by a small fascicle of the levator labii superioris alaque nasi muscle. The facial vein lied very close to the periosteum of the frontal process of the maxilla under the medial
band of the orbicularis oculi muscle. The mean vertical distance from the facial vein to the inferior orbital rim was 6.87 ± 1.14 mm (Fig. 3). 3.2. Level of the canine fossa
D. Chinnawong et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 27 (2015) 645–649
Fig. 2. The horizontal distance from the facial vein to the ala of nose (pink pin) is depicted by line “A” and horizontal distance from the facial vein to the oral commissure (green pin) is shown by line “B”. The diameter of the facial vein and the depth from the skin was measured at the green circle. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
of the zygomaticus major and platysma muscle medial to the buccal fat pad. It crossed the body of the mandible lateral to the facial artery. In half of the specimens the facial vein crossed the insertion of the masseter muscle and entered the neck at the inferior margin of the mandible. The distance between the facial vein and the anterior border of the masseter muscle was 3.81 ± 7.20 mm. At the level of oral commissure, the average horizontal distance from the facial vein to oral commissure was 27.55 ± 3.97 mm. The mean diameter of the facial vein was 2.98 ± 0.92 mm. The average depth from the skin surface to the facial vein was 15.38 ± 2.40 mm (Fig. 4).
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wrinkles and folds caused by the repetitive movement of facial muscles, in addition to laxity induced by the force of gravity [9]. Dermal fillers can improve facial volume and reduce the appearance of fine wrinkles. However, complications can occur after the dermal fillers injection such as artery obstruction, allergic reaction and inflammation, necrosis, ulceration and arterial embolization [7,11]. Although previous studies have reported on arterial complications as a result of dermal fillers injection, venous complications have not been extensively studied especially with regard to the facial vein. This vein is susceptible to injury during dermal fillers procedure. Therefore, surface landmarks of the facial vein must be emphasized and recognized by dermatologists who inject the dermal fillers into the face. The facial vein is considered a large vein of the face. It is a continuation of the angular vein that begins at the medial canthal ligament of the eye. It runs obliquely downward along the side of nose and passes under the zygomaticus major muscle. It descends along the anterior border and crosses the anterior recess of the masseter muscle insertion, subsequently crossing over the body of the mandible into the neck. In our study, we determined the course, diameter, and location of the facial vein based on the soft tissue landmarks such as oral commissure, ala of nose and inferior orbital rim while commenting on the relationship with surrounding structure for identification of appropriate dermal fillers injection sites. Previous studies reported surface landmarks commonly used for locating the facial vein in the facial region as mandibular angle, mental protuberance, gnathion and cheilion (oral commissure) [12,13]. The facial vein lies on the periosteum of the medial part of the inferior orbital rim. The mean vertical distance from the orbital rim to the vein was 6.87 ± 1.14 mm. This area at the medial side of the eye should be considered as the most susceptible to facial vein injury. Dermal filler injections to correct eye bags or tear trough deformity at the lower eyelid should be carefully performed to avoid inadvertently injecting into the facial vein at this site. This suggestion is due to the technique commonly used for treating tear trough deformity is recommend injecting the filler at the supraperiosteal level along or below the orbital rim under the defect or both [14]. We suggest the clinicians to inject the fillers in superficial
3.4. Relationships between the facial vein and the surrounding structures This study investigated the course of the facial vein related to the surrounding structures, especially the facial and the masseter muscles. In this study, we found that the facial vein was superficial to the levator labii superioris muscle in all specimens and deep to the zygomaticus minor muscle in 20 (66.7%) specimens and superficial to this muscle in 10 (33.3%) specimens. The facial vein crossed the lower border of the mandible and drained into the neck vein. In 15 (type 1, 50%) specimens the facial vein located lateral to the anterior border of the insertion of the masseter muscle. The facial vein located medial to the muscle insertion at the anterior recess in 11 (type 2, 36.7%) specimens. In 4 (type 3, 13.3%) specimens the facial vein ran between the anterior recess and the anterior border of the masseter muscle (Table 1). 4. Discussion Aging of the face is a very complex process involving three important factors: global facial volume loss, dynamic and static
Fig. 3. The vertical distance (red line “C”) from the facial vein (arrow) to the inferior orbital rim. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
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Fig. 4. The diagram of the facial vein course. The blue line presents the course of the facial vein. The mean distance from the inferior orbital to the facial vein was 6.87 mm. The mean distance between the facial vein and the ala of nose was 21.57 mm. The mean distance of the facial vein to the oral commissure was 27.55 mm. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
layer, subcutaneous layer, for preventing the facial vein complications. Using an imaginary line from the lateral canthus to the cheilion, Lohn et al. located the facial vein at a distance of 3.2 ± 0.08 cm from the cheilion to the point of crossing virtual line (chilion–canthus) [12]. In this study we selected a closer distance by measuring along the horizontal line. The distance between the facial vein and ala of nose was 21.57 ± 3.95 mm at the depth of 14.44 ± 2.90 mm. The site of injection recommended for softening the nasolabial folds is at the area extending 2 mm lateral and 2 mm medial to the nasolabial fold [15]. Taking these data into consideration, injecting filler at the ala of nose and the nasolabial fold would avoid injury since we located the facial vein at a distance far away from these injection areas. Thus, they can be regarded as safe injection sites. To restore the cheek volume, clinicians should inject the fillers into the subdermal plane [16]. Therefore, the facial vein is safe from the needle because its lies on deep layer. Measurements at the level of the cheilion, taken from the current study, are in agreement with the study by Lohn et al. The distances between the facial vein and the cheilion in this study and the study by Lohn et al. were 27.55 ± 3.97 mm and 2.8 ± 0.05 cm, respectively [12]. As such, during filler injection of the buccal area to correct volume loss in this region, clinicians should be aware of the facial vein position at the level of the cheilion mentioned above at the depth of 15 mm. The facial vein is safe from the marionette augmentation because the injection into the dermal and subdermal planes begins along the lower white roll of the lip horizontally about 1 cm in length from the oral commissure [17]. From
Table 1 The number and percentage of the relationship type between the facial vein and the insertion of the masseter muscle. Relationship
Number
Type 1 Type 2 Type 3
15 11 4
Total
30
Percentage (%) 50 36.7 13.3 100
this study, the facial vein locates rather deep, so the clinicians must inject the fillers in subcutaneous layer to avoid the facial vein. In a previous study the distances between the facial vein and the mandibular angle and the mental protuberance were 2.71 ± 0.48 and 4.67 ± 0.68 cm, respectively [13]. Alternatively, our study involved measuring the distance between the facial vein and the anterior border of the massester muscle at the lower margin of mandible, an easily locatable soft tissue landmark. The facial vein lies 3.8 ± 7.20 mm anterior to the masseter insertion. This position of the facial vein must be avoided to prevent substantial ecchymosis when filler is injected to correct the pre-jowl sulcus in a patient with “jowling” [18]. In this region, the facial vein lies on closely to the periosteal layer, so the clinicians should inject the fillers into the subcutaneous layer to avoid the facial vein injury. Several previous studies have not reported on the depth of facial vein and the possible complications that can arise from needle injury. In this study, we present the depths measurement of the facial vein at the levels of the lateral border of ala of nose and the oral commissure. We suggest that the suitable depth for clinical injection must not exceed 14 mm from the skin to avoid the facial vein injury. The relationships between the facial vein and the surrounding structures have not been reported in previous studies, and we observed these relationships for identification of the facial vein during reconstructive procedures. We found that the facial vein is superficial to the levator labii superioris muscle in all specimens, deep to the zygomaticus minor muscle in two-third of specimens, and lateral to the insertion of the masseter muscle in half of all specimens. 5. Conclusion The facial vein runs a large curved course without tortious from the medial canthral ligament downward along the medial orbital rim and the rim of the malar eminence just lateral to the infraorbital foramen. It usually lies very close to the periosteal layer of the maxilla within a thin layer of retroperiosteal fat. Then it crosses the anterior border of the masseter muscle to make an acute tune under the inferior margin of the mandible. The facial vein is still safe if the clinicians inject the dermal filler into the subcutaneous layer. Acknowledgement Miss Yasmina M E Sahraoui from University of Liverpool for the revision of this manuscript. References [1] Wulc AE, Sharma P, Czyz CN. The anatomic basis of midfacial aging. Midfacial Rejuvenation. Springer; 2012. p. 15–28. [2] Sherman RN. Avoiding dermal filler complications. Clin Dermatol 2009;27:S23–32. [3] Narins RS, Baumann L, Brandt FS, Fagien S, Glazer S, Lowe NJ, et al. A randomized study of the efficacy and safety of injectable poly-l-lactic acid versus humanbased collagen implant in the treatment of nasolabial fold wrinkles. J Am Acad Dermatol 2010;62:448–62. [4] Requena L, Requena C, Christensen L, Zimmermann US, Kutzner H, Cerroni L. Adverse reactions to injectable soft tissue fillers. J Am Acad Dermatol 2011;64:1–34. [5] Alsuhaibani AH, Alfawaz N. Lower eyelid swelling as a late complication of Bio-Alcamid filler into the malar area. Saudi J Ophthalmol 2011;25:75–9. [6] Park TH, Seo SW, Kim JK, Chang CH. Clinical experience with hyaluronic acidfiller complications. J Plast Reconstr Aesthet Surg 2011;64:892–6. [7] Kim DW, Yoon ES, Ji YH, Park SH, Lee BI, Dhong ES. Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in management. J Plast Reconstr Aesthet Surg 2011;64:1590–5. [8] Goldenberg D, Netzer A, Gallimidi Z, Joachims HZ, Danino J, Golz A. Thrombophlebitis of the facial vein: a case report and review. Otolaryngology – Head and Neck Surg 1999;121:P237–8. [9] Buck II DW, Alam M, Kim J. Injectable fillers for facial rejuvenation: a review. J Plast Reconstr Aesthet Surg 2009;62:11–8.
D. Chinnawong et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 27 (2015) 645–649 [10] Sclafani AP, Fagien S. Treatment of injectable soft tissue filler complications. Dermatol Surg 2009;35:1672–80. [11] Bellman B. Complication following suspected intra-arterial injection of Restylane. Aesthet Surg J 2006;26:304–5. [12] Lohn JW, Penn JW, Norton J, Butler PE. The course and variation of the facial artery and vein: implications for facial transplantation and facial surgery. Ann Plast Surg 2011;67:184–8. [13] Cicekcibasi AE, Yılmaz MT, Seker M. The Mandibular Landmarks about the Facial Artery and Vein with Multidetector Computed Tomography Angiography (MDCTA): an Anatomical and Radiological Morphometric Study. Int J Morphol 2012;30:504–9.
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[14] Carruthers J, Rzany B, Sattler G, Carruthers A. Anatomic guidelines for augmentation of the cheek and infraorbital hollow. Dermatol Surg 2012;38:1223–33. [15] Dayan SH, Bassichis BA. Facial dermal fillers: selection of appropriate products and techniques. Aesthet Surg J 2008;28:335–47. [16] Braz AV, Sakuma TH. Midface rejuvenation: an innovative technique to restore cheek volume. Dermatol Surg 2012;38:118–20. [17] Hilinski JM, Cohen SR. Soft tissue augmentation with ArteFill. Facial Plast Surg 2009;25:114–9. [18] Graivier MH, Bass LS, Busso M, Jasin ME, Narins RS, Tzikas TL. Calcium hydroxylapatite (Radiesse) for correction of the mid- and lower face: consensus recommendations. Plast Reconstr Surg 2007;120:55S–66S.
Contents lists available at ScienceDirect
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology journal homepage: www.elsevier.com/locate/jomsmp
Original Research
Surface landmark of the facial vein for the dermal fillers injection Dawinee Chinnawong ∗,1 , Tanvaa Tansatit 1 , Piyaporn Phanchart 1 , Natthida Rachkaew 1 The Chula Soft Cadaver Surgical Training Center and Department of Anatomy, Faculty of Medicine, Chulalongkorn University and the King Chulalongkorn Memorial Hospital, 1873 Rama 4 Road, Pathumwan, Bangkok 10330 Thailand
a r t i c l e
i n f o
Article history: Received 17 March 2014 Received in revised form 3 October 2014 Accepted 19 January 2015 Available online 26 February 2015 Keywords: Facial vein Soft tissue landmarks Dermal fillers injection
a b s t r a c t Objective: The purpose of this study was to describe the course of the facial vein and identification of surface landmark of the facial vein for dermal fillers injections. Methods: Thirty flaps of hemiface were turned over to measure the distance between the facial vein and ala of the nose and oral commissure. The vertical distance was measured from the inferior orbital rim to the facial vein. The diameter of the facial vein and the depth from skin surface to the facial vein were measured. Anatomical relationships of the facial vein to its surrounding structure were observed. Results: The course of the facial vein is a large curved course without tortious from the medial canthal tendon downward along the medial orbital rim. The mean vertical distance from the facial vein to the inferior orbital rim was 6.87 ± 1.14 mm. The average horizontal distance from the facial vein to ala of nose was 21.57 ± 3.95 mm. The average horizontal distance from the facial vein to oral commissure was 27.55 ± 3.97 mm. The average depth values from skin surface to the facial vein at the level of ala of nose and oral commissure were 14.44 ± 2.90 and 15.38 ± 2.40 mm, respectively. Conclusions: The course of the facial vein at the level of ala of nose and the oral commissure were approximately 2 and 3 cm, respectively at the depth of 1.5 cm. © 2015 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽
1. Introduction An aging face is a multifactorial process with anatomic, biochemical, and genetic elements. Many exogenous and endogenous factors such as solar exposure, cigarette smoking, medications, alcohol use, body mass index, and endocrinologics status have been implicated as factors that accelerate the facial aging process [1]. In recent years, the number of cosmetic dermatology procedures performed has increased. There are several types of treatment to help combat an aging face such as surgery, botulinum toxin and dermal fillers injection. Among these techniques, the dermal fillers injection is the most commonly used for aging face treatment. Dermal fillers involve filling the wrinkle or crease by the injection of an appropriate filler substances. There are many different types such
夽 Asian AOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asian Society of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathology; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japanese Society of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants. ∗ Corresponding author. Tel.: +66 0899821440; fax: +66 2 2527028. E-mail address: Dew [email protected] (D. Chinnawong). 1 Tel.: +66 0818094414; fax: +66 2 2527028.
as fat, collagen (bovine, human, and purified porcine), hyaluronic acids (HAs), calcium hydroxylapatite (CaHA), and injectable medical devices such as poly-l-lactic acid (PLLA) microspheres [2,3]. The ideal fillers injectable for an aging face should be safe, stable at the implantation site, painless to inject, and minimal complication [4,5]. Complication of dermal fillers injection can be varied and include bleeding, allergic reactions, lower eyelid swelling, and facial vein thrombophlebitis after infection. More serious complications can range from anaphylactic reaction, skin and tissue necrosis, blindness and death [5–9]. It is important for dermatologists to be well informed on the position of anatomical structures beneath the skin at the site of injection. This is because during a filler procedure the needle may come in contact with structures beneath the skin, specifically the facial vein, potentially resulting in venous occlusion [10]. That is often delayed, and presents as a dull pain with bluish discoloration that may simulate a bruise. Therefore, the accuracy knowledge of surface landmarks of the facial vein may help reduce the serious complication that can occur as a consequence of this procedure. The purpose of this study was to describe the course of the facial vein along with accuracy surface landmarks to ultimately allow identification of appropriate dermal filler injection sites.
http://dx.doi.org/10.1016/j.ajoms.2015.01.015 2212-5558/© 2015 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽
646
D. Chinnawong et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 27 (2015) 645–649
2. Materials and methods Dissection was performed on 30 hemi-face specimens of soft embalmed cadavers, from Chula Soft Cadaver Surgical Training Center of King Chulalongkorn Memorial Hospital. Selection criteria required specimens with no history of trauma or surgical procedure on the face. All cadavers were donated to the institute for medical education and research was carried out with the written consent of the family delegate. 2.1. Dissection of the cadavers Firstly, a skin incision was made on the forehead roughly 2 cm above the eyebrows and continued around the temporal region, anterior to the external ear canal, to the mandibular angle of the jaw line on both sides and along the mandibular border to the midline. All skin and subcutaneous tissue was removed by lifting from underneath the periosteal layer using a periosteal elevator or a surgical blade. The origin and insertion of the temporalis and the masseter muscles were cut to allow removal. An incision was made around the alveolar bone to detach the facial muscle from the maxilla and mandible. For each orbit, the orbital septum was severed from its attachment on the orbital rim. The periorbital was deflected from the orbital rim and continued toward the optic canal and orbital fissure. The optic nerves and additional structures were cut to remove the contents of both orbital cavities. The nasal cartilage was cut and removed as deep as possible to keep the nose intact, and lifted away along the mucosa of the lateral walls of the maxilla along with the head of the inferior turbinate. This allowed the facial flap to be removed en bloc with the facial musculature and innervations still intact. The facial flap was turned over to allow examination to be performed from a periosteal view. 2.2. Observation and measurement
Fig. 1. The facial vein (red arrow) ran beneath the levator labii superioris (LLS) muscle and the zygomaticus minor (Zm) muscle and crossed over the zygomaticus major (ZM) muscle, while running between the branches of buccal branch (green arrow) of the facial nerve. The facial vein ran under the parotid duct (P) and buccinator muscle (B) along the anterior border of the masseter muscle (M). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
Following attainment of the facial flap, the buccal fat pad was removed to allow identification of the facial vein situated beneath the parotid duct. We observed the course of the facial vein from the anterior border of masseter muscle to the medial canthal ligament (Fig. 1). The horizontal distances between the facial vein and ala of nose and oral commissure were measured using calipers. The vertical distance from the inferior orbital rim to the facial vein was also measured. The diameter of the facial vein and the depth from the surface of the skin were measured at the level of ala of nose and oral commissure (Fig. 2). Additionally, the anatomical relationship between the facial vein and the surrounding structures was observed. At the lower border of the mandible two anatomical landmarks were defined: the anterior palpable border of the masseter and its anterior recess at the inferior mandibular margin. We divided the relationship of the facial vein with the insertion of the masseter muscle into 3 patterns as follows: Type 1, the facial vein was situated lateral to the anterior border of the insertion of the masseter muscle. Type 2, it crossed the mandibular margin medial to the anterior recess. Type 3, it ran between the anterior recess and the anterior border.
The facial vein coursed between the origin of the levator labii superioris muscle and (under) the medial band of the orbicularis oculi muscle just medial to the malar eminence. It ran along the medial orbital rim above the infraorbital foramen for a short distance where it deviated and descended downward before it reached the origin of the masseter muscle. In every specimen the facial vein lied superficial to the sublevator space as well as superficial to all four descending branch of the infraorbital nerve up to the ala of nose and upper lip. At the level of ala of nose, the average horizontal distance from the facial vein to ala of nose was 21.57 ± 3.95 mm. The mean diameter of the facial vein was 2.44 ± 0.72 mm. The average depth from the skin surface to the facial vein was 14.44 ± 2.90 mm (Fig. 1).
3. Results
3.3. Level of the masticator space
3.1. Level of the medial canthal ligament
At the level of the masticator space the facial vein descended obliquely along the medial border of the buccal fat pad and the masseter muscle. In this area the facial vein was usually found accompanying the middle or the lower trunk of the buccal branch of the facial nerve. The superior labial vein running from the medial side drained into the facial vein. It reached the genu of the parotid duct while the parotid duct looped around the masseter muscle to enter the buccinator muscle. The facial vein lied under the insertion
The facial vein crossed over the medial canthal ligament together with a few branches of the angular nerve from the upper buccal branch of the facial nerve. At the medial canthal ligament, the facial vein was covered by a small fascicle of the levator labii superioris alaque nasi muscle. The facial vein lied very close to the periosteum of the frontal process of the maxilla under the medial
band of the orbicularis oculi muscle. The mean vertical distance from the facial vein to the inferior orbital rim was 6.87 ± 1.14 mm (Fig. 3). 3.2. Level of the canine fossa
D. Chinnawong et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 27 (2015) 645–649
Fig. 2. The horizontal distance from the facial vein to the ala of nose (pink pin) is depicted by line “A” and horizontal distance from the facial vein to the oral commissure (green pin) is shown by line “B”. The diameter of the facial vein and the depth from the skin was measured at the green circle. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
of the zygomaticus major and platysma muscle medial to the buccal fat pad. It crossed the body of the mandible lateral to the facial artery. In half of the specimens the facial vein crossed the insertion of the masseter muscle and entered the neck at the inferior margin of the mandible. The distance between the facial vein and the anterior border of the masseter muscle was 3.81 ± 7.20 mm. At the level of oral commissure, the average horizontal distance from the facial vein to oral commissure was 27.55 ± 3.97 mm. The mean diameter of the facial vein was 2.98 ± 0.92 mm. The average depth from the skin surface to the facial vein was 15.38 ± 2.40 mm (Fig. 4).
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wrinkles and folds caused by the repetitive movement of facial muscles, in addition to laxity induced by the force of gravity [9]. Dermal fillers can improve facial volume and reduce the appearance of fine wrinkles. However, complications can occur after the dermal fillers injection such as artery obstruction, allergic reaction and inflammation, necrosis, ulceration and arterial embolization [7,11]. Although previous studies have reported on arterial complications as a result of dermal fillers injection, venous complications have not been extensively studied especially with regard to the facial vein. This vein is susceptible to injury during dermal fillers procedure. Therefore, surface landmarks of the facial vein must be emphasized and recognized by dermatologists who inject the dermal fillers into the face. The facial vein is considered a large vein of the face. It is a continuation of the angular vein that begins at the medial canthal ligament of the eye. It runs obliquely downward along the side of nose and passes under the zygomaticus major muscle. It descends along the anterior border and crosses the anterior recess of the masseter muscle insertion, subsequently crossing over the body of the mandible into the neck. In our study, we determined the course, diameter, and location of the facial vein based on the soft tissue landmarks such as oral commissure, ala of nose and inferior orbital rim while commenting on the relationship with surrounding structure for identification of appropriate dermal fillers injection sites. Previous studies reported surface landmarks commonly used for locating the facial vein in the facial region as mandibular angle, mental protuberance, gnathion and cheilion (oral commissure) [12,13]. The facial vein lies on the periosteum of the medial part of the inferior orbital rim. The mean vertical distance from the orbital rim to the vein was 6.87 ± 1.14 mm. This area at the medial side of the eye should be considered as the most susceptible to facial vein injury. Dermal filler injections to correct eye bags or tear trough deformity at the lower eyelid should be carefully performed to avoid inadvertently injecting into the facial vein at this site. This suggestion is due to the technique commonly used for treating tear trough deformity is recommend injecting the filler at the supraperiosteal level along or below the orbital rim under the defect or both [14]. We suggest the clinicians to inject the fillers in superficial
3.4. Relationships between the facial vein and the surrounding structures This study investigated the course of the facial vein related to the surrounding structures, especially the facial and the masseter muscles. In this study, we found that the facial vein was superficial to the levator labii superioris muscle in all specimens and deep to the zygomaticus minor muscle in 20 (66.7%) specimens and superficial to this muscle in 10 (33.3%) specimens. The facial vein crossed the lower border of the mandible and drained into the neck vein. In 15 (type 1, 50%) specimens the facial vein located lateral to the anterior border of the insertion of the masseter muscle. The facial vein located medial to the muscle insertion at the anterior recess in 11 (type 2, 36.7%) specimens. In 4 (type 3, 13.3%) specimens the facial vein ran between the anterior recess and the anterior border of the masseter muscle (Table 1). 4. Discussion Aging of the face is a very complex process involving three important factors: global facial volume loss, dynamic and static
Fig. 3. The vertical distance (red line “C”) from the facial vein (arrow) to the inferior orbital rim. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
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Fig. 4. The diagram of the facial vein course. The blue line presents the course of the facial vein. The mean distance from the inferior orbital to the facial vein was 6.87 mm. The mean distance between the facial vein and the ala of nose was 21.57 mm. The mean distance of the facial vein to the oral commissure was 27.55 mm. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
layer, subcutaneous layer, for preventing the facial vein complications. Using an imaginary line from the lateral canthus to the cheilion, Lohn et al. located the facial vein at a distance of 3.2 ± 0.08 cm from the cheilion to the point of crossing virtual line (chilion–canthus) [12]. In this study we selected a closer distance by measuring along the horizontal line. The distance between the facial vein and ala of nose was 21.57 ± 3.95 mm at the depth of 14.44 ± 2.90 mm. The site of injection recommended for softening the nasolabial folds is at the area extending 2 mm lateral and 2 mm medial to the nasolabial fold [15]. Taking these data into consideration, injecting filler at the ala of nose and the nasolabial fold would avoid injury since we located the facial vein at a distance far away from these injection areas. Thus, they can be regarded as safe injection sites. To restore the cheek volume, clinicians should inject the fillers into the subdermal plane [16]. Therefore, the facial vein is safe from the needle because its lies on deep layer. Measurements at the level of the cheilion, taken from the current study, are in agreement with the study by Lohn et al. The distances between the facial vein and the cheilion in this study and the study by Lohn et al. were 27.55 ± 3.97 mm and 2.8 ± 0.05 cm, respectively [12]. As such, during filler injection of the buccal area to correct volume loss in this region, clinicians should be aware of the facial vein position at the level of the cheilion mentioned above at the depth of 15 mm. The facial vein is safe from the marionette augmentation because the injection into the dermal and subdermal planes begins along the lower white roll of the lip horizontally about 1 cm in length from the oral commissure [17]. From
Table 1 The number and percentage of the relationship type between the facial vein and the insertion of the masseter muscle. Relationship
Number
Type 1 Type 2 Type 3
15 11 4
Total
30
Percentage (%) 50 36.7 13.3 100
this study, the facial vein locates rather deep, so the clinicians must inject the fillers in subcutaneous layer to avoid the facial vein. In a previous study the distances between the facial vein and the mandibular angle and the mental protuberance were 2.71 ± 0.48 and 4.67 ± 0.68 cm, respectively [13]. Alternatively, our study involved measuring the distance between the facial vein and the anterior border of the massester muscle at the lower margin of mandible, an easily locatable soft tissue landmark. The facial vein lies 3.8 ± 7.20 mm anterior to the masseter insertion. This position of the facial vein must be avoided to prevent substantial ecchymosis when filler is injected to correct the pre-jowl sulcus in a patient with “jowling” [18]. In this region, the facial vein lies on closely to the periosteal layer, so the clinicians should inject the fillers into the subcutaneous layer to avoid the facial vein injury. Several previous studies have not reported on the depth of facial vein and the possible complications that can arise from needle injury. In this study, we present the depths measurement of the facial vein at the levels of the lateral border of ala of nose and the oral commissure. We suggest that the suitable depth for clinical injection must not exceed 14 mm from the skin to avoid the facial vein injury. The relationships between the facial vein and the surrounding structures have not been reported in previous studies, and we observed these relationships for identification of the facial vein during reconstructive procedures. We found that the facial vein is superficial to the levator labii superioris muscle in all specimens, deep to the zygomaticus minor muscle in two-third of specimens, and lateral to the insertion of the masseter muscle in half of all specimens. 5. Conclusion The facial vein runs a large curved course without tortious from the medial canthral ligament downward along the medial orbital rim and the rim of the malar eminence just lateral to the infraorbital foramen. It usually lies very close to the periosteal layer of the maxilla within a thin layer of retroperiosteal fat. Then it crosses the anterior border of the masseter muscle to make an acute tune under the inferior margin of the mandible. The facial vein is still safe if the clinicians inject the dermal filler into the subcutaneous layer. Acknowledgement Miss Yasmina M E Sahraoui from University of Liverpool for the revision of this manuscript. References [1] Wulc AE, Sharma P, Czyz CN. The anatomic basis of midfacial aging. Midfacial Rejuvenation. Springer; 2012. p. 15–28. [2] Sherman RN. Avoiding dermal filler complications. Clin Dermatol 2009;27:S23–32. [3] Narins RS, Baumann L, Brandt FS, Fagien S, Glazer S, Lowe NJ, et al. A randomized study of the efficacy and safety of injectable poly-l-lactic acid versus humanbased collagen implant in the treatment of nasolabial fold wrinkles. J Am Acad Dermatol 2010;62:448–62. [4] Requena L, Requena C, Christensen L, Zimmermann US, Kutzner H, Cerroni L. Adverse reactions to injectable soft tissue fillers. J Am Acad Dermatol 2011;64:1–34. [5] Alsuhaibani AH, Alfawaz N. Lower eyelid swelling as a late complication of Bio-Alcamid filler into the malar area. Saudi J Ophthalmol 2011;25:75–9. [6] Park TH, Seo SW, Kim JK, Chang CH. Clinical experience with hyaluronic acidfiller complications. J Plast Reconstr Aesthet Surg 2011;64:892–6. [7] Kim DW, Yoon ES, Ji YH, Park SH, Lee BI, Dhong ES. Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in management. J Plast Reconstr Aesthet Surg 2011;64:1590–5. [8] Goldenberg D, Netzer A, Gallimidi Z, Joachims HZ, Danino J, Golz A. Thrombophlebitis of the facial vein: a case report and review. Otolaryngology – Head and Neck Surg 1999;121:P237–8. [9] Buck II DW, Alam M, Kim J. Injectable fillers for facial rejuvenation: a review. J Plast Reconstr Aesthet Surg 2009;62:11–8.
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