Facial Anatomy: Facial Artery and Path

Facial Anatomy: Facial Artery

• The facial artery has a specific path across the face.
• In the lower third of the face (mandibular region), it runs deep and is protected by muscles like the platysma and the lower border of the masseter muscle.
• In the middle third of the face (jugal region), it becomes more superficial, notably along the nasolabial fold, making it more vulnerable.
• It originates from the external carotid artery and follows a winding course to supply blood to the facial region.

Facial Artery Path:

• It begins at the external carotid artery, just above the lingual artery.
• It passes under the mandible at the lower border, typically near the angle between the ascending branch and the body of the mandible.
• It travels sinuously forward and upward in the cheek, moving in front of the masseter muscle, and then curves around the labial commissure.
• It gives rise to the superior and inferior labial arteries, which supply the lips.
• It continues toward the nose, forming the angular artery, which connects with the dorsal artery of the nose, originating from the ophthalmic artery.

Risk Areas in Aesthetic Treatments:

• Labial Commissure Region:
  • Presence of the superior and inferior labial arteries increases embolization risk during filler injections.
  • Deep injections can cause vascular obstruction and tissue necrosis.
• Nasolabial Fold and Nasal Ala Region:
  • This area contains the angular artery, which is the terminal branch of the facial artery and inappropriate filling can lead to retrograde embolization towards the ophthalmic artery, risking blindness.
• Chin Region:
  • It includes the mental artery, which emerges from the mental foramen and is a branch of the inferior alveolar artery.
  • Use a special attention when filling this area, especially with deep injections.
• Periorbital and Dorsal Nasal Region:
  • This is where the facial artery connects with the ophthalmic artery through the angular artery.
  • Injecting filler inappropriately may cause significant and major vascular complications.

Precautions in Aesthetic Medicine:

• Use cannulas instead of needles in high-risk areas to reduce vascular perforation risks.
• Inject deeply or subdermally, following anatomical guidelines.
• Inject slowly with prior aspiration to check for intra-arterial injection.
• Monitor for early signs of vascular complications, such as skin blanching, intense pain, and livedo reticularis.

Facial Foramen:

• The face contains three main bony foramina (openings) through which nerves and arteries pass.
• Supraorbital Foramen:
  • Located on the frontal bone, above the orbit.
  • It allows passage of the supraorbital nerve and artery, branches of the ophthalmic nerve (V1) and ophthalmic artery.
• Infraorbital Foramen:
  • Situated on the maxilla, below the orbit.
  • It transmits the infraorbital nerve (branch of the maxillary nerve V2) and artery, which supply the facial region below the eye.
• Mental Foramen:
  • Found on the mandible, at the level of the chin.
  • It allows passage of the mental nerve (branch of the inferior alveolar nerve from the mandibular nerve V3) and mental vessels.
• These foramina are essential exit points for facial innervation and vascularization.

Structures Passing Through the Foramen:

• Supraorbital Foramen (frontal bone):
  • Contains the supraorbital nerve (V1 branch) and the supraorbital artery, which supply the forehead, scalp, and upper eyelid.
  • Contains the supraorbital vein, which drains the frontal region and communicates with ophthalmic veins.
• Infraorbital Foramen (maxillary bone):
  • Contains the infraorbital nerve (V2 branch), which innervates the skin of the lower eyelid, nasal ala, upper lip, and nasolabial region.
  • Contains the infraorbital artery, supplying the suborbital region and the cheek.
  • Contains the infraorbital vein, draining blood from the suborbital region and connecting with the pterygoid venous plexus.
• Mental Foramen (mandibular bone):
  • Contains the mental nerve (V3 branch), providing innervation to the skin of the chin and lower lip.
  • Contains the mental artery, supplying the chin region.
  • Contains the mental vein, draining the mental region and communicating with facial veins.

Identifying the Foramen during Consultation:

• The three foramina are key anatomical landmarks for aesthetic medicine and local anesthesia.
• Supraorbital Foramen (frontal bone):
  • Palpation- Locate a small depression about 2-3 cm laterally from the midline, by placing a finger under the superior border of the orbit.
  • It is aligned vertically with the pupil when the patient looks straight ahead.
  • Test for sensitivity- Gentle pressure may trigger a sensation in the forehead and scalp.
  • Local anesthesia for frontal injections or inject away from the site to avoid vascular damage.
• Infraorbital Foramen (maxillary bone):
  • Palpation- Locate 1 cm below the bony ridge, under the lower border of the orbit.
  • It is aligned vertically with the supraorbital and mental foramina.
  • From 0.5 to 1 cm below the midline of the lower eyelid. -Test for sensitivity- Gentle pressure may cause sensation in the cheek, upper lip, and nasal wing.
  • Local anesthesia for the cheek and nasolabial fold treatment or avoid site to prevent vascular occlusion.
• Mental Foramen (mandibular bone):
  • Palpation- Locate on the chin, slightly toward the top, approx, at a mid-distance and half way from the lower border to the junction of premolars.
  • Aligned vertically with both infraorbital and supraorbital foramina.
  • Test for Sensitivity- Gentle pressure may cause tingling or numbness in the lower lip and chin.
  • Local anesthesia for chin or lower lip treatments, avoiding the nerve to minimize discomfort.

Quick References for Identifying the Foramens:

• Vertical Alignment:
  • Supraorbital foramen: midline above the orbit.
  • Infraorbital foramen: aligned with the pupil under the orbit.
  • Mental foramen: at the level of the chin, between the premolars.
• Tactile Method: Palpate for a small bony depression.
• Sensitivity Test: Confirm location by testing sensitivity.
• Precautions:
  • Do not inject directly into the foramen to prevent vascular or nerve damage to prevent arterial injection

SMAS (Superficial Musculo-Aponeurotic System):

• The SMAS is a fibrous and muscular layer beneath the skin and subcutaneous fat of the face.
• Composed of connective tissue and muscle fibers, it connects the skin to facial muscles.
• It is Present in the middle and lower face, extending from the scalp to the neck and is continuous with the platysma in the cervical region and the superficial temporal fascia superiorly.
• Its role- Maintains facial structure and tension, supports skin and subcutaneous tissues, transmits facial muscle movements to the skin and plays a part in facial aging.
• During a Surgical lift, modern techniques involve repositioning the SMAS for a more natural and long-lasting result.
• For Thread-lifting, threads are inserted into the layer to enhance traction and skin retention.
• For Filler Injections, follow the SMAS dynamics to avoid a stiff appearance.

SOOF (Sub-Orbicularis Oculi Fat):

• Fatty compartment, located under the orbicularis oculi muscle in the suborbital region.
• The location of it is under the inferior orbital rim and between the orbicularis muscle and the periorbital layers.
• Its role- To support and protect the suborbital region.
• It acts as a shock absorber between the eye's bone structure and muscles.
• Key influence on the aging process as it descends through the years, creating a loss of volume under the eye and deepening the circles.
• The applications- repositioned with a blepharoplasty to correct bulges.
• Restore volume loss with hyaluronic acid injections, and with mid-facial lifting it can restore the original youthfulness.

ROOF (Retro-Orbicularis Oculi Fat):

• Fatty Compartment located above the orbicularis oculi in the superior orbit, lies under the eyebrow.
• It is connected with fatty tissue of the forehead
• Its role- Influences eyebrows appearance by its presence and the volume of the upper eyelid.
• Influences position and looks of the eyebrows.
• Aging- It can be descendent over time, or can enlarge, leading to a droopy appearance off the eye-lid and sagging eyebrows.
• Apply blepharoplasty to reduce, or inject bots or fat to give a lift.

Key Distinctions Between SOOF and ROOF

• Position: SOOF is deep and under the orbicularis oculi, while ROOF is superficial and located at the top of it.
• Treatments for the different zones are different and must be implemented individually.

Ligaments Responsible for Volume Changes with Age

• The loss of tension and support through the ligaments leads to sagging or a lack of volume in certain areas.

Facial Ligaments

• Orbital Ligament (orbito-malar ligament):
  • Role: Attaches skin and soft tissues to the lower edge of the eye socket dividing the orbital region from the cheek.
  • Affect of aging: SOOF descent (sub-orbital fat), under eye hollows of a valley, or swollen bags. -Treatments: HA injection to replenish lost volume or blepharoplasty to reimplantate tissues.
• Zygomatic cutaneous ligament(malar ligament):
  • Role: Connects the skin and soft tissues with the zygomatic arch.
  • Affect of aging: Sagging or descent of cheek tissues creating malar fat bags (excess fat and water retention).
  • Treatments: Water retentions, lifting or volume injections can help replace the lost support.
• Naso-labial ligament:
  • Role: Anchors the nose-lip fold while it stabilized mid face area.
  • Affect of aging: Los of flexibility resulting in droopy tissues in mid-face region, resulting in strong nose lip folds. -Treatments: HA injections and lifting of threads
• Mandibular Ligament: -Role: Fixes skin and muscles to the jaw. -Affect of aging: Hollowing of the skin and folding (vertical lines) and shifting the the fat down the lower portion of the face by drooping.

Other key Ligaments

Temporal-Malar Ligament (zygomatico-temporal):

• Connects the temporal bone with the temple region.
• Affect of aging: Hollow or sinking temples, which result in strong skeletal features.
• Treatment: HA to temples.

Masseteric cutaneous Ligament (parotidien ligament):

• Connects skin to parotid glad and masseter muscle, on the side of the jaw. Affect of aging: Loose of definition of face, and sagging cheeks/jowls.
• Treatments: Cervico-facial lifts, mini lifting, threads or fillers.

Cervico-mandibular ligament (platysmo-mentonnier):

• Connects platysma with mandible
• Affect of aging: Double chin
• Treatments: Botox, lipo or lifts.

Pre-masseterin ligament (bucco-masseterin ligament):

• Connects cheek and jaw
• Affect of aging: Fatigued look, deep nose and lip fold
• Treatments: Injection and filling of lifts.