Knowing the facial anatomy is fundamental to performing more than aesthetic surgery. A provider’s lack of understanding of the intricate web of facial muscles, nerves, arteries and more can turn a relatively simple injection technique, with botulinum toxin or a filler, into a serious complication.
“All injectors — dermatology to facial plastic and plastic surgery to oculoplastic and maxillofacial surgeons — should have a very good knowledge of the facial anatomy,” says Manolis G Manolakakis, D.M.D., director of the facial cosmetic surgery fellowship at RWJ Barnabas-Monmouth Medical Center, a diplomate of American Board Facial Cosmetic Surgery and fellow of the American Academy Cosmetic Surgery. “That includes the subcutaneous planes of anatomy: different nerves, muscles, as well as blood vessels, and whether they’re arteries, veins, big ones, little ones. This is especially important around periocular areas.”
Without a comprehensive anatomical understanding, a physician injecting dermal fillers, for example, might inject into a vessel, causing a catastrophic event, like blindness. Blindness might also result from Kenalog or steroid injections. The problem is there are vessels that have no valves, and fillers can cause clots in a retinal artery, he says.
Skin necrosis also occurs when injectors don’t fully understand facial anatomy, according to Dr. Manolakakis.
And bad outcomes — they’re yet another result of not knowing the facial anatomy.
Botulinum toxin, for example, works by blocking the neurotransmitter from the nerve and nerve-ending fiber that goes into the muscle. So, providers injecting into the forehead or glabella need to know the muscle anatomy, the functions of the muscles, as well as the effects to surrounding muscles. But that’s not all. They also have to know the opposing muscles and what they’re going to do in reaction to weakening one of others, according to Dr. Manolakakis.
Having the needed education is more important than ever for injectors. Traditionally, filler injections were done in the nasolabial folds. But, now, because of new filler types and a better understanding of what’s youthful and more beautiful, injections to other areas of the face are common, including the cheeks, temples, periorbital areas, eyebrows, lips and jawline.
“The concept of injections, especially with the dermal fillers, has evolved,” Dr. Manolakakis says. “It has changed from filling in a line to creating proper proportions, different curves and different volumization, and beautifying the entire face,” Dr. Manolakakis says.
Dr. Manolakakis offers these pearls for The Aesthetic Channel’s facial injection anatomy at-a-glance.
MUST-KNOW: Procerus muscle, corrugator muscle, depressor supercilii muscle; supraorbital and supratrochlear nerves; and arteries and veins.
FILLER INJECTABLE OF CHOICE: Volbella (Allergan), for superficial etched lines.
WHERE TO INJECT AND WHY: “If you’re injecting the glabellar and periorbital area, or the crow’s feet, those muscles will depress or bring down the eyebrows. So, if you want to get a lift, it’s a good idea to inject those muscles. Then, if you don’t inject the opposing forehead muscle, you’ll see a net effect of a lifting of the eyebrow. That’s because the opposing muscles, the forehead or frontalis muscles, will raise the brow,” Dr. Manolakakis says.
WHAT CAN GO WRONG ANATOMY-WISE: “Typically, if you’re injecting a neurotoxin into a blood vessel, the neurotoxin just will not work, and you will most likely get a bruise,” he says. “If you inject filler into one of the vessels, you can potentially get skin necrosis or even blindness, as these vessels connect with the central retinal and ophthalmic retinal arteries and veins.”
MUST-KNOW: orbicularis oculi
INJECTABLE OF CHOICE: Any neuromodulator for dynamic rhytids. For dermal fillers, Vollure or Volbella (Allergan).
WHERE TO INJECT AND WHY: Inject under the muscle.
WHAT CAN GO WRONG ANATOMY-WISE: “The angular artery is of importance when injecting under the eye,” Dr. Manolakakis says. “A good way to avoid it is to not take your needle or cannula into the area, but rather stop short and then massage your filler into that region.”
MUST-KNOW: The provider needs to be able to identify the bony landmarks of the zygomatic arch, zygoma and infraorbital rim.
INJECTABLE OF CHOICE: “Voluma (Allergan) is my choice of injectable because it has the best ability to lift. The Vycross technology allows the product to inter-collate between the tissues.”
WHERE TO INJECT AND WHY: “The infraorbital neurovascular bundle is important. Palpate the foramen,” he says. “The transverse facial artery and vein are above the muscle, so you want to inject below the muscles and above the periosteum.”
WHAT CAN GO WRONG ANATOMY-WISE: Bruising, asymmetry; again, possible ischemia and or blindness is a potential if injection is not under muscle, Dr. Manolakakis says.
MUST-KNOW: “The folds are very interesting area of the face,” he says. “Outside the folds, we have skin, subcutaneous tissue, SMAS [Superficial muscular aponeurotic system], muscle, periosteum, bone. On the inside of the fold, we have skin, SMAS, muscle, and it is very tightly bound.”
INJECTABLE OF CHOICE: “The injectable of choice, for me, is either Juvéderm Ultra Plus or Vollure [Allergan], depending on how much fill I need. If less fill, then Vollure; if I need more, then Juvéderm Ultra Plus,” he says.
WHERE TO INJECT AND WHY: Injection is with cannula and it’s at the deep dermis.
WHAT CAN GO WRONG ANATOMY-WISE: “The facial artery and vein runs fairly close and turns into the angular artery and vein. Again, skin necrosis and blindness are of concern in this area,” Dr. Manolakakis says.
MUST-KNOW: orbicularis oris
INJECTABLE OF CHOICE: “I use a combination of Vollure and Volbella. For more robust lips, I use Juvéderm Ultra Plus,” he says.
WHERE TO INJECT AND WHY: “Inject into the submucosal, near the wet-dry line for volume and, for definition, closer to vermillion,” Dr. Manolakakis says. “Stay away from oral mucosa side.”
WHAT CAN GO WRONG AND WHY: Bruising, necrosis.
DISCLOSURE: Dr. Manolakakis is an Allergan Medical Institute Educator.