An understanding of the vascular supply of the eyelids and face is crucial during facial surgery, as well as when performing nonsurgical facial procedures such as soft-tissue filler augmentation and neurotoxin chemodenervation. Although very rare (<0.001–0.5%), direct injection into a facial artery can result in skin necrosis; this has been reported for every filler type. The risk is highest for procedures performed in the glabella due to its limited collateral circulation; the supraorbital, supratrochlear, infraorbital, and angular arteries are the most vulnerable. Early signs of arterial vascular compromise are pain and skin pallor; signs of venous occlusion often have a delayed onset, presenting as dull pain and skin discoloration.
The most devastating adverse outcome associated with soft-tissue fillers is blindness resulting from occlusion of the ophthalmic artery and its branches. An intravascular bolus of filler can reach the ophthalmic artery via retrograde flow from any number of facial arteries, in particular, the dorsal nasal, angular, supratrochlear, or supraorbital vessels (Activity 9-1; Fig 9-9). Vision loss is often profound (no light perception) and permanent. Dissemination of filler in a facial artery can also result in focal brain infarctions, leading to hemiplegia and dysarthria. In rare instances, vascular occlusions in the periorbital area can also result in ophthalmoplegia and ptosis.
Arterial danger zones of the face during filler injection. Illustration courtesy of Mark Miller, based on a sketch by Cat N. Burkat, MD.
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Figure 9-8 The face receives its sensory innervation from the 3 branches of CN V: V1, ophthalmic; V2, maxillary; and V3, mandibular.
(Modified with permission from Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 7th ed. Baltimore: Lippincott Williams & Wilkins; 2013:851.)
Park KH, Kim YK, Woo SJ, et al; Korean Retina Society. Iatrogenic occlusion of the ophthalmic artery after cosmetic facial filler injections: a national survey by the Korean Retina Society. JAMA Ophthalmol. 2014;132(6):714–723.
Figure 9-9 Arterial danger zones of the face. Shading denotes areas to inject with caution.
(Illustration courtesy of Mark Miller, based on a sketch by Cat N. Burkat, MD.)
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.