SUMMARY

NERVES AND VESSELS

Congratulations on completing course 'Nerves and Vessels'
This course summary will cover the nerves and vessels of the upper, mid and lower face.

Facial veins and arteries

The complex and sometimes unpredictable blood supply to the face means that you MUST have a sound
knowledge of facial anatomy, especially the location of key arterial and venous structures, BEFORE carrying
out injections with aesthetic products.

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Major branches of the external carotid artery:

1) Maxillary artery – supplies the deep structures of the face
2) Facial artery – arterial blood supply to lips and mid-face
3) Superficial temporal artery – supplies the lateral part of the face, temple, forehead and scalp

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The internal carotid artery enters the skull and supplies the
central forehead, eyelids and upper part of the nose via
supraorbital, supratrochlear, dorsal nasal and lacrimal
branches of the ophthalmic artery that may form anasto-
moses with the external carotid system through the angular
artery.1

Arteries of the upper face

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Arteries of the mid face

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The superficial veins of the face and scalp are remarkably proximal to their corresponding arteries.

It is important to know how to carry out detailed examination and palpation to locate vessels and avoid injury
to the regional blood supply during aesthetic procedures. In a worst case scenario, occlusion of the ophthal-
mic artery or its branches can lead to visual impairment or blindness.

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High-risk areas for arterial/venous occlusion when injecting with dermal fillers and volume

Danger zone Relevant structures

1. Glabella  upratrochlear artery
S
 Supraorbital artery
 Dorsal nasal artery
Occlusion of the ophthalmic artery or its branches may lead to loss of vision.2
 rea of highest risk for necrosis – vessels are small and do not have a good
A
source of collateral circulation.3

2. Temple  uperficial temporal artery

S
 Supraorbital artery (which anastomoses with the superficial
temporal artery)
 Anterior deep temporal artery
 Posterior deep temporal artery
 Middle temporal artery
Injection into temporal vessels can block the blood supply to the retina,
leading to loss of vision.2

3. Cheek   Facial artery

 Transverse facial artery
 Buccal branch of the maxillary artery
  Infraorbital artery
 Zygomatic branch of the lacrimal artery (which arises close to the optic foramen)
Injection into distal branches of the ophthalmic artery can block the blood supply
to the retina, leading to loss of vision.

4. Nose   Dorsal nasal artery

5. Lower face/jawline
 Angular artery 3
 Lateral nasal artery
Compression with large volumes of filler or direct injection into vessels can
lead to necrosis of nasal alar, nasal tip, nasolabial fold and upper lip.3
  Facial artery
 Superior and inferior labial arteries
 Submental artery
 Mental artery
Injection into distal branches of the ophthalmic artery can block the blood
supply to the retina, leading to loss of vision.

Enhancers:
Typical signs of vascular compromise are:3,4

Impending necrosis, as indicated by the following:

1) Intense pain in the treatment area
2) Skin blanches or becomes mottled grey and this persists for >2–3 minutes
3) Skin turns blue indicating that necrosis is imminent

Impending vision loss, as indicated by the following:

1) Ocular pain in the affected eye immediately after injection
2) Diminished vision
3) Ophthalmoplegia (extra-ocular muscle palsy)

A rapid response is vital to quickly promote blood supply to the affected area.

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Immediate management involves:
 Applying warm compresses – no ice
 Massaging or tapping the area to facilitate vasodilation and dispersion of material
 Using hyaluronidase
 Providing aspirin
 Applying a topical vasodilator – the consensus is to use nitroglycerin

Facial and sensory nerves

The facial nerve is the seventh of 12 paired cranial nerves (CN VII). It innervates the muscles of facial
expression1 and carries taste sensations from the anterior two-thirds of the tongue and oral cavity.

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The motor portion of the facial nerve emerges from the skull at the stylomastoid foramen in the temporal
bone and terminates within the parotid gland where it divides into five major branches. These branches
facilitate the expressions of the face by innervating certain muscles.

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Expression Muscle Nerve branch(es)
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Surprise Occipitofrontalis Temporal

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The eyebrow com- Corrugator Temporal
ponent of frowning supercilii

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as if sniffing

5
© MERZ INSTITUTE Blinking, squinting, Orbicularis oculi Temporal and
forceful closing of zygomatic
the eyelids

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laughing major; zygomaticus buccal
minor; risorius

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The trigeminal nerve is the fifth of 12 paired cranial nerves (CN V). It is primarily responsible for sensory
innervation of the face.1

The trigeminal nerve is divided into three major branches:

Nerve Provides sensation to:

Ophthalmic nerve Scalp, forehead, upper eyelid and nasal bridge
(CN V1)

Maxillary nerve L ower eyelid, nasal sidewalls and columella,

(CN V2) temple and upper lip

Mandibular nerve Lower lip, chin, mandible and preauricular areas

(CN V3)

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The ophthalmic and maxillary nerves are purely sensory, while the mandibular nerve also has certain motor
functions, such as biting and chewing.1 The sensory nerves are typically located more superficially than the
motor nerves, along the junction of the fat and the submuscular aponeurotic system. This protects the
motor nerves from injury.

Nerve damage
Although rare, inadvertent nerve injury can be caused by the following: 6
 Needle piercing or partially lacerating the nerve
 Injection of filler into the nerve
 Tissue compression by product or local swelling
 Excessive moulding and massaging of product into a nerve foramen

Motor nerve damage can result in serious functional and cosmetic morbidity.6
Sensory nerve injury can lead to tingling (paraesthesia) or loss of sensation (anaesthesia) in the area sup-
plied by the nerve. Paraesthesia and anaesthesia occur most commonly around the infraorbital foramen and,
in cases of nerve compression by filler, removal or dilution of the product around the nerve root may be
helpful. The effects are usually reversible and sensation typically returns within several months.6

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Sensory nerves and pain management
Awareness of the sensory branches of the face allows the use of nerve blocks as part of aesthetic
treatments, which provide effective anaesthesia with minimal discomfort for the patient.

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Infraorbital and mental nerve blocks are most commonly used in aesthetic procedures. However, other
nerves (including the supratrochlear (1), supraorbital (2) and zygomaticofacial nerves (3)) can be targeted 7
too, depending on the treatment being administered.7–9

Utilising facial foramina

The skull transmits nerves and blood vessels through openings known as foramina. These foramina can be
used to locate the nerves and blood vessels of the face.

Provides blood
Artery/nerve Foramen description and sensation to:
Supratrochlear artery and Leave the orbit through the Medial forehead and
nerve 8,10 supratrochlear notch or foramen eyebrow
Supraorbital artery and Leave the orbit through the supraorbital Corrugator muscle
nerve 1, 8,10 notch or foramen
Mental artery and Emerge from the mental foramen and Facial muscles and skin of the chin
nerve 1,7 run towards the end of the chin and anastomoses
Infraorbital artery and nerve 1,7 Exit through the infraorbital foramen Middle third of the face

Zygomaticofacial artery and Exit the bone through the zygomati- Triangular area from the lateral
nerve 1,9 cofacial foramen in the inferior lateral canthus, and the malar region
portion of the orbital rim along the zygomatic arch

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The facial lymphatic system
Before carrying out any aesthetic procedure, it is important to understand facial lymph flow, especially in the
periorbital area and infraorbital hollows.

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The facial lymph glands or nodes comprise: 11

1) Infraorbital or maxillary: found in the infraorbital region from the nose–cheek groove to the zygomatic arch 8
2) Buccinator: one or more found on the buccinator opposite the angle of the mouth
3) S
 upramandibular, found on the outer surface of the mandible, in front of the masseter and contacting the
external maxillary artery and anterior facial vein

Lymphatic drainage has relevance to aesthetic procedures.

Periorbital muscle movement has an important role in the drainage of local fluids. Careful patient assessment
before e.g. toxin procedure in periorbital region is vital to assess if the patient has any pre-existing lymphatic
compromise

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Injection of dermal fillers into the infraorbital hollow and tear trough can cause malar oedema as a result of
compromised lymphatic drainage.12

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The incidence of malar oedema can be reduced by appropriate patient and filler selection, limiting filler
volume, and placing filler deep to the malar septum. Some fillers with very specific properties can be placed
in the subcutaneous plane superficial to the area prone to lymphatic obstruction.6

References 9
1.  Prendergast P. Anatomy of the Face and Neck: Cosmetic Surgery. Eds. Shiffman M, Di Giuseppe
A. Berlin Heidelberg; Springer-Verlag: 2012.
2. Carle M, et al. JAMA Ophthalmol 2014;132:637–9.
3. Emer J, Waldorf H. Clin Dermatol 2011;29:678–90.
4. Brennan C. Plas Surg Nurs 2014;34:108–11.
5. Inglefield C, et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler
Treatment. London; Aesthetic Medicine Expert Group: 2014.
6. Funt D, Pavicic T. Clin Cosmet Investig Dermatol 2013;6:295–316.
7.  B
 usso M. Guidelines for Local Anesthesia in Use of Injectable Fillers. Injectable Fillers: Principles
and Practice. Ed. Jones D. Oxford, UK; Wiley-Blackwell: 2010.
8. M
 edscape. Supratrochlear Nerve Block. Available at:
http://emedicine.medscape.com/article/1826449-overview#aw2aab6b3.
Last accessed: 13 April 2015.
9. Niamtu J. Cosmet Dermatol 2004;17:645–7.
10. Thomaidis VK. Cutaneous Flaps in Head and Neck Reconstruction: From Anatomy to Surgery.
Berlin Heidelberg; Springer-Verlag: 2014.
11. Gray H. Gray’s Anatomy (37th Edition). Eds. Williams PL, Warwick R, et al. Edinburgh; Churchill
Livingstone: 1989.
12. Funt D. J Clin Aesthet Dermatol 2011;4:32–6.

Abbreviations
CN V, fifth cranial nerve; CN VII, seventh cranial nerve

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