Facial Anatomy View for AestheticFillers Injections

Bhertha Tamura

ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Skin Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Dermis and Subcutaneous Tissue of the Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Limits of the Facial Zones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Facial Bones (Altruda Filho et al. 2005; Gardner et al. 1978; Tamura 2010a, b;Sobotta and Becher 1977) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Forehead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Orbit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Facial Prominence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9External Nasal Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Maxilla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Mandible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Temporalis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Fossa Temporalis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Description of the Main Facial Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Sensitive Innervation of the Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Forehead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Eyelids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Auricle-Temporal, Cheek, Mandible, and Maxilla Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Buccal Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Motor Innervation (Facial Nerve) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

B. Tamura (*)Clínicas Hospital of São Paulo of the University of SaoPaulo, Sao Paulo, Brazil

Barradas and Bourroul’s Ambulatório de Especialidades inSao Paulo, Sao Paulo, Brazil

Sorocaba’s Ambulatório de Especialidade in Sorocaba,Sao Paulo, Brazile-mail: bhertha.tamura@uol.com.br

# Springer Nature Switzerland AG 2019M. C. A. Issa, B. Tamura (eds.), Botulinum Toxins, Fillers and Related Substances, Clinical Approaches andProcedures in Cosmetic Dermatology 4, https://doi.org/10.1007/978-3-319-20253-2_16-2

1

Facial Vasculature (Altruda Filho et al. 2005; Gardner et al. 1978;Tamura 2010a, b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Lymphatic System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

AbstractThe therapeutic armamentarium for facial reju-venation has changed over the years. Fillersand the comprehension of the aging processhave evolved rapidly. The techniques havechanged and facial anatomy needs to be betterunderstood. Fat compartments and bone agingand reabsorption are responsible for aging of theface. Therefore they are key for facial rejuvena-tion. The most important anatomical referencesfor facial aging treatment are the fat compart-ment, the vasculature, and the bones, but alsothe muscular interaction, the neural complex,and even the subcutaneous and full skin thicknessneed to be studied. The risks and drastic conse-quences of arterial occlusion have haunted phy-sicians. To get a successful outcome and tominimize complications, it is necessary to ana-lyze the facial anatomy and to recognize whichareas should be volumized or filled to promotelifting aspect. It is possible when fillers are deeplyinjected at specific points, acting as vectors.

KeywordsFillers · Anatomy · Arterial occlusion ·Amaurosis · Adverse events · Implants · Facialanatomy · Rejuvenation · Aging · Bone ·Vascular · Necrosis

Introduction

The evolution of facial rejuvenation has advancedover the last few years, with new techniquesand different approach of global facial aging.The main points to be considered are: boneabsorption, mimic muscles contraction, fat com-partments, which are influenced by environmentand patient’s habits. Special attention must begiven to certain areas such as glabellar, ocular

and nasal due to the risk of arterial occlusion,ischemia and embolism during filling procedure.

Botulinum toxin for muscle dynamics treat-ment is used for a long time in Cosmetic Derma-tology, but the introduction of different types offillers changed the concept of filling procedure.Nowadays, fillers are used not only to refill, butmainly to restructure the face and to replace facialfat pads. These new techiniques require a deepknowlegde of facial anatomy to avoid importantcomplications, such as vascular occlusion.

Skin Anatomy

The skin is the widest barrier of the human bodyand besides protection, it does prevent dehydra-tion. The superficial layer of the skin, thekeratinized layer, can be exfoliated during treat-ments through chemical and mechanical peel-ings or by using different laser devices. The re-epithelization depends upon the basal layer’sintegrity and the pilosebaceous unit. Theepidermis extends to the basal layer wheremelanocytes, Langerhans, and Merkel cells arelocated.

The dermis, one of the most important struc-tures, plays an important role in the wrinklingprocess of the skin due to its collagen and elasticfibers, cellular components, and vascular supply.This area is resistant, for example, to needle punc-tures because of its firm, compact, and less dis-tensible characteristics. This is also the layer thatcan sense pain due to its sensitive innervation.Any product injected at the dermis forms a painfuland very superficial papule, and these are the signsthat indicate we have reached this layer.

The subcutaneous layer comprehends the fattissue, right under the dermis, divided into anareolar layer where the vessels and nerves are

2 B. Tamura

mostly located, and under it, divided by a tinyfascia, the lamellar layer or the hypodermis. Atthis point, the fat compartments are also kept intheir own location by their fascia. Its thickness,the fat compartments, and their position have animportant role in the global facial aging process.

This paragraph about skin anatomy does notrequire a detailed histological description butshould be considered to understand depth andthe techniques for the injection of fillers to correctlines in the skin. Arlette and Trotter (2008)reported that the thickness of the dermis at thenasolabial fold varies from 1.32 to 1.55 mm. Con-sidering that the needle bezel’s length varies from0.75 to 0.95 and the needle diameter varies from0.3 to 0.4 mm, the old trick of inserting the needleat 30 � to reach the superficial dermis and at 45 � toreach the deep dermis, or to visualize the needleby skin transparency, does not represent the real-ity, especially considering that different areas ofthe body and face have variations. Therefore, themajority of fillers are injected into the superficialsubcutaneous layer, and not the dermis, even byhighly experienced doctors.

Dermis and Subcutaneous Tissueof the Face

The skin of the forehead is thicker than the inferiorportion of the face. Under the skin, there are:the subcutaneous tissue; the galea-aponeurotic,part of the Subcutaneous Muscular Aponeu-rotic System (SMAS); the areolar subaponeuroticlayer and the periosteum. Due to the local anatomy,overcorrection of the frontal lines is easily noticedwith minimal excessive amounts of fillers, in theform of papules, nodules, or lines of the skin in thefrontal area and the bone structure. Through theintroduction of new products, as nonparticulatehyaluronic acids, and new techniques, it is possibleto fill fine lines properly as well as to remold theforehead creases, caused by a fat loss in the medialand lateral frontal fat compartments.

At the temporal area, the skin is relatively thin,and many times the superficial temporal arterymight be seen as quite a linear pulsing line with athicker connective tissue, and also two extensive

deep and superficial fat compartments. The super-ficial fat pad extends to the preauricular and poste-rior area of the mandible and the deepest fatcompartment to the medial area of the facereaching the Bichat area (Gardner et al. 1978). Atthe subcutaneous layer, massive arterial branchesof the temporal artery are found along the temporalneural branches. It is possible that the injection offillers intravascularly might spread an embolus toany region of the face and the cranium and evencause amaurosis or necrosis. Due to these anatomicfeatures, most physicians prefer to inject fillers withcannulas or in bolus at the supraperiosteal layer,right into the intersection point between 1 cm underthe temporal crest of the frontal bone and 1 cmabove the eyebrow. This point has been used forsafer injection, as it avoids the artery and the migra-tion of the filler, when injected in a greater amount,to the Bichat area.

The facial superficial fat layer is dense becauseof thefibrous septum and it is scarce at the forehead,glabella, and temporal and orbital areas (Fig. 1).

Fig. 1 The facial superficial fat layer is dense due to thefibrous septum and is scarce at the forehead, glabella,temporal, and orbital area

Facial Anatomy View for Aesthetic Fillers Injections 3

The suborbicularis oculi fat (SOOF) is locatedinferiorly to the zygomaticus bone and under themuscle. It is separated from the periorbital fatthrough a thin orbital and malar septum. Theptosis of the SOOF could be responsible forthe lateral malar ptosis at the orbital rim thatmight be seen during the aging process. Whenfillers are injected at the medial palpebral malarsulcus (tear trough) and the lateral palpebral malarsulcus, we need to remember the medial and lat-eral palpebral ligaments (Fig. 2). These ligamentsmust be considered when we are planning to cor-rect not only the medial and lateral palpebralmalar sulcus but also the upper lid orbital rim.They need to be filled separately as the fillercannot progress upward from the inferior orbitalrim through the ligaments.

The eyebrows position also has basic parame-ters of normality that need to be respected whenfillers, botulinum toxin, or facial sculpture areplanned (Goldberg 2008). The eyebrows shouldbe positioned 5 or 6 cm below the hair implanta-tion, the medial portion at a perpendicular line thatcrosses the lateral nasal alae and 1 cm above themedial canthus of the eyes. The lateral portion ofthe eyebrow (in back – Fig. 1) ends at an obliqueline of the base of the alar cartilage of the nosethrough the lateral canthus of the eyes (red line –Fig. 1). The medial and lateral areas of the eye-brow should be horizontal and at the same level(in blue – Fig. 1) (Fig. 3). Women’s eyebrows areabove the supraorbital margin and in an archshape with the higher point at the lateral limboof the eye, next to the junction of the medial two-

thirds with the lateral third of the eyebrow. Thearch is smaller and slightly below the supraorbitalmargin in men (Pessa and Rohrich 2012).

The fat tissue at the malar area, the nasolabialfold, and the mandible is dense. The fat pad at themalar area is divided into jugal and mandibular,and the deep portions might be found between themuscles. The Bichat fat pad is localized anterior tothe masseter muscle and deeper to the posteriorfascia of the buccal region. Their anatomic loca-tion should be analyzed balancing the shape of theface to correctly program the right volume and thedepth for the injection of fillers thus planning anatural result and not as a huge artificial implant.Differences in men and women also need to beconsidered properly.

At the malar prominence, we face the muscle-cutaneous perforating vessels and one or twozygomatic nerve foramen depending upon indi-vidual variations. With aging, there is ptosis andpseudo herniation of the SOOF and the orbital fatpads. The laxity of the medial malar area leads tofat accumulation at the anterior and inferior por-tion of the cheeks and there is also fat loss at thelateral superior malar area. These changes lead toa deep nasolabial fold, multiple lines at thecheeks at smiling mimics, and a pseudo fold atthe submalar area. The vector that pulls the facedownward does also lead to a skeletonizedappearance of the malar region and this iswhere the filling techniques mentioned comeinto play (Carruthers et al. 2009; Pessa andRohrich 2012; Sadick et al. 2009). Fig. 4 showsthe facial fat pads.

Orbucularis m.

Lateral PalpebralLigament Medial Palpebral

Ligament

Lateral PalpebralLigament

Medialligament

Orbicularis m.

Fig. 2 Medial and lateral palpebral ligaments, the periocular muscle, and the medial ligament

4 B. Tamura

The skin adheres to the risorius and platysmamuscles at the parotideal masseteric area. Thefacial nerve branches (Fig. 5) and the parotidealduct (Fig. 6) are located posterior to the SMAS

and anterior to the masseter and the buccal fat pad.When we inject fillers at this area, we mustremember that the parotideal duct is right underan imaginary line from the mouth corner to the

The height of the medial ending of theeyebrow coincides with the height ofthe lateral ending

An imaginary line fromthe medial ending of theeyebrow coincides withthe lateral nasal alae

The distance from the hairimplantation to the eyebrowshould be between 5 to 6 cmThe distance

from themedial endingof the eyebrowto the eye innercanthus shouldbe 1cm

An imaginary linefrom the lateral ending of theeyebrow coincides with the lateral eyecanthus and to themouth angle

1 cm

Fig. 3 Standardparameters of the eyebrowspositioning

Fig. 4 The left picture shows the superficial facial fat pads;at the middle, the arrow points to the the retroorbicularisoculi fat (ROOF) (8); the picture on the right shows the deepfacial fat pads. (1) nasolabial fat pad; (2) medial cheek pad;(3) middle cheek pad; (4) lateral temporal cheek pad; (5)

Temporal fat pad; (6) superior palpebral fat; (7) inferiorpalpebral fat; (9) sub-orbicularis oculi fat (medial part);(10) deep medial fat pad (medial part); (11) deep medialfat pad (lateral part); (12) buccal extension of the bucal fat;(13) sub-orbicularis oculi fat (lateral part)

Facial Anatomy View for Aesthetic Fillers Injections 5

tragus. We need to be aware of an accidentalfistulae due to a ductal trauma during injections.The parotideomasseteric fascia (connective layer)that originates the risorius muscle also envelopesthe parotid gland and the masseter muscle(Altruda Filho et al. 2005).

Skin, cartilage, and bone supporting a connec-tive tissue and ligaments keep everything togetherat the nose. The skin is thick and adheres to theinferior third and it is thinner and mobile at thesuperior two-thirds of the nose (Fig. 7). Althoughthese structures are intimately bonded, fillers canbe injected without any problem and when wellindicated, migration of the products is extremelyrare (depending upon the volume, technique, orproduct).

FacialNerve

FacialNerve

Fig. 5 Location of the facial nerve

Parotidduct

Parotidduct

Fig. 6 Parotid’s duct

Fig. 7 The nasal structure combines the skin, the carti-lage, and the bone

6 B. Tamura

Around the lips, the skin is thick and just overthe muscular layer. The vermillion of the lips has atransitional epithelium between the skin and themucosa that is thin and delicate. On the otherhand, at the lateral canthus of the lips, the subcu-taneous tissue is important for the adherence ofthe local muscles and the lips mucosa. During theaging process, frequent perioral movements leadto mimic lines, so-called “bar codes,” around thelips. Vessels are found at the medial area and theintimate adhesion of the mucosa and musclesexplain why fillers must be injected at the dermis.Therefore, physicians must choose the right fillerto get the best result, avoiding overcorrection anddeformities of the superior lips without evensmoothing the lines properly. The number of tor-tuous vessels at the deeper layer of the lips mightresult in hematoma, depending upon the tech-nique of injection.

The chin’s skin is thin and the mentual muscleis located right under it, depressor labia muscle isright beside, and the depressor anguli oris and theplatysma muscle are located laterally to it andat the labiomarginal sulcus (Fig. 8). The adiposetissue that is superficial to the SMAS adheresfirmly to the dermis through a fibrous septumand laterally all the tissues connect straight to thebone at the retainer ligament. This firm attachmentleads to longer discomfort when higher amountsof fillers are injected to reshape the mental area.

Earlobes can also be corrected with fillers,improving laxity (aging process) or giving firm-ness after a plastic reconstruction. Fillers not onlyfill up the lobe and reshape it, but add an extrafirmness to the preauricular area. Earlobes aredelicate structures with thin epidermis andmedium thickness dermis and subcutaneous tis-sue. The vessels at the subcutaneous layer are verythin and evenly distributed.

Limits of the Facial Zones

The superior third of the face is limited by animaginary line from the tragus to the lateral can-thus of the eyes, contouring the inferior eyelid

bordering the nasal radix to the eyebrow line.The limits of the medium third are the line of thesuperior third, from tragus to the lateral canthus ofthe mouth, contouring the border of the upper lipto the tragus of the other side. The inferior third’ssuperior limit is the medium zone contouring theinferior border of the lower lip until the mandib-ular line (Fig. 9).

The temporal area is anteriorly limited by thetemporal portion of the zygomaticus bone, poste-riorly by the supramastoid crest, superiorly by thetemporal line, inferiorly by a horizontal line thatcrosses the zygomaticus arch, laterally by theskin, and medially by the frontal, sphenoidal,parietal, and temporal bones.

There is a temporal space limited laterally orsuperficially by the temporalis fascia (that coversthe superficial branch of the temporalis muscle)and medially or deeply the superficial branch ofthe temporalis muscle. There is a superficial fatpad and a deep fat pad. The deepest communicatesto the masticator and buccal area. It is also medi-ally or deeply limited by the superficial branch ofthe temporalis muscle.

The infratemporal region is limited superiorlyby the infratemporal side of the major branch ofthe sphenoidal bone, inferiorly the inferior linetangential to the mandible basis, laterally the inter-nal side of the mandible branch, medially thelateral aspect of the lateral lamina of the pterygoidprocess and the superior and medium constrictormuscle of the larynx, anteriorly by the maxillaetuber, and posteriorly by the parotid gland(Tamura 2013).

The orbicular area is divided into lateral por-tion, medial canthus, superior and inferior lacri-mal area, and superior and inferior lid.

The infraorbicular, zygomaticus, and thecheeks limits are anteriorly the external nose,nasolabial and labiomarginal sulcus, posteriorlythe anterior margin of the masseter, superiorlythe infraorbital margin, and inferiorly the mandib-ular base. The cheeks limits are the malar complexsuperiorly and inferiorly the mandible and itsshape determined by the parotid gland, the mus-cles, and the buccal fat pad. Deeply to the muscles

Facial Anatomy View for Aesthetic Fillers Injections 7

of the infraorbital, zygomaticus, and cheek region,the mucosa extends between the superior andinferior fornix of the buccal vestibule and theperiosteum that covers the bones of this region.

The ideal location of the malar prominence is10 mm lateral and 15 mm inferior to the exter-nal canthus of the eye. Deficiencies of this mea-surement lead to an elongation of the maxillaadded, most of the times, to a lack of projectionof the medium third of the face. The submalartriangle is an inverted depressed triangle of themid face limited superiorly by the zygoma prom-inence, medially by the nasolabial sulcus, andlaterally by the body of the masseter.

The parotideomasseteric region is limitedsuperiorly by the anterior margin of the masseterand posteriorly by the mastoid process and theanterior margin of the sternocleidomastoid

muscle. The superior limit is the zygomaticusarch until the external acoustic meatus; the infe-rior, the tangential line of the mandible basis untilthe mastoid process, and the medial, the styloidprocess (posteriorly) and the lateral side of thepharynx (anteriorly). The pterygopalatine corre-sponds to the same named fossa, localized deeplyat the face and superiorly to the palate, inferiorlyto the sphenoidal sinus, anterior to the pterygoidfossa, posteriorly to the orbit and the maxillarysinus, laterally to the nasal cavity, and medially tothe infratemporal fossa; it resembles an upside-down pyramid with a square base (superior) withan apex (inferior) and four walls.

Concerning the nasal area, it is limited superi-orly by both eyebrows, inferiorly in a linedesigned tangential to the nasal basis, and laterallybetween the medial angle of the eye to thenasolabial fold. This area is divided into radix(superior part of the nose), the dorsum, and theapex of the nose (the tip) and nostrils. The dorsumcorresponds to the right and left walls of the nasalbasis; the dorsum that is the right and left lateralwalls of the nose between the base, radix, andnostrils that correspond to the elevator of theinferior part of the nasal dorsum. The nasolabialangle stays between 90� and 100� in men andbetween 100� and 110� in women.

When analyzing the labial limits, the superioris the base of the nose; the lateral, the nasolabialsulcus; the superior lateral, the nasolabial fold; the

Fig. 8 Mentual, depressorlabii, depressor anguli orisand platysma musclesintimately related at the chin

Fig. 9 Limits of the facial zones: superior, medium, andinferior thirds

8 B. Tamura

inferior, the labiomental fold; and the inferiorlateral, the labiomarginal fold. The extension ofthe lips is greater than the red portion of theadjacent skin. It is an anatomical unit that extendssuperiorly to the nose and inferiorly to the men-tum. The perfect lip structure includes a whiteline, or transitional, visible between the mucosaand the skin, a long median tubercle, a “V” shape(known as Cupid’s bow), the vermillion, and theascendant line of the buccal commissure. Thegolden proportion (the perfect measure) of thelips is 1:1618 (in width and thickness). Thephiltrum is an important reference at the centralarea of the upper lip outlined by two columns ofthe philtrum vertically oriented, and Cupid’s bowis the concavity at the base of the philtrum.

The superior limit of the mental region is thelabiomental sulcus, the interior is the mandiblebasis, and the lateral, the labiomarginal fold. It islimited between the mental foramens and the cen-tral part of the mandible. The lateral medium zoneextends from the posterior mental foramen to theoblique line of the horizontal body of the mandi-ble and the lateral/posterior is limited by the pos-terior half of the body, including the angle and thefirst 2–4 cm of the ascendant branch of the man-dible. The submental zone is the lower area of thementum and localizes between the platysma bandand of the cervico-mental angle.

Facial Bones (Altruda Filho et al. 2005;Gardner et al. 1978; Tamura 2010a, b;Sobotta and Becher 1977)

The bones that delimitate the cranial cavity pro-tecting the encephalon and the meninges arethe frontal, the ethmoid, the occipitalis, thetemporalis, and the parietal bones; the formertwo come as pairs. The frontal, nasal, lachrymal,zygomaticus, maxilla, and the mandibular bonesare located at the facial area. The vomer is odd,and those in pairs (the palatines and the inferiornasal shells) are deeper. The deep grafts and fillersat the face are mostly located at the nasal, malar(zygomaticus and superior maxilla), and mental(gnathion and mental protuberance) bones(Figs. 10, 11, and 12).

Forehead

The forehead bone is the frontal bone; and at thecaudal part, each side of the medial line articulateswith the nasal bone. The nasion (Fig. 13) is theintersection of the frontal and both nasal bones,and the area above the nasion between the eye-brows is the glabella. From the glabella, the eye-brows extend laterally to both lateral sides.

Orbit

The eyes are located at the orbital cavity, which isdivided into superior, lateral, interior, and medialborder.

The frontal bone is the superior border orsupraorbital area. The supraorbital vessels andnerve emerge from the supraorbital notch, medi-ally to the notch and at the margin of the frontalbone (Fig. 13). Nowadays, the line that describesbetter the location of the three main sensitiveforamens of the face is considered to be the onethat crosses the limbo of the eyes, and not themedial pupillary line. The supraorbital marginends laterally to the zygomaticus process of thefrontal bone, and in each supraorbital margin, thefrontal bone directs posteriorly as most of theceiling of the pars orbitalis. The zygomaticusand frontal bone from the lateral side and theinferior are formed by the maxilla and thezygomaticus. The medial area of the orbit isshaped by the maxillaries, lacrimal, and frontalbone. Under the inferior border of the orbit at thepupil line, the maxilla has a foramen, theinfraorbital foramen (Fig. 12) where theinfraorbital vessels and nerve emerge.

Facial Prominence

The malar bone (zygomaticus) forms the facialprominence at the inferior and lateral border ofthe orbit and lies on the maxilla. Thus, there is alateral surface, an orbital side that contributes tothe lateral wall of the orbit and a temporal surfaceat the temporal fossa. The frontal process articu-lates with the zygomaticus process of the frontal

Facial Anatomy View for Aesthetic Fillers Injections 9

bone and the temporal with the zygomaticusprocess of the temporal bone. At the lateralportion, the zygomaticus bone is perforated bythe facial zygomaticus foramen (Fig. 13), andthe nerve block performed in this area canreduce pain during malar procedures. (see chap-ter ▶ “Facial Nerve-Block Anesthesia in Cos-metic Dermatology”).

External Nasal Bone

The external nasal bone is constituted by the nasalbones limited by the maxillaries and ending ante-riorly at the piriform aperture (Fig. 10). The softtissue of the external nose is formed by a carti-lage structure (medium and lateral) that joins thepiriform aperture through a fibrous tissue. The

Cheekbone

Nasalbone

Frontalbone

Infraorbital bone

MaxillaZygomaticusarch

Pyriform aperture

Fig. 10 Facial area bones

Parietal bone

Anterior temporalcrest

TemporalisSphenoid

Occipital boneZygoma

Fig. 11 Lateral vision ofthe cranial bones

10 B. Tamura

domus is the junction of the medial and lateralcartilages, the shape of the tip of the nose dependsupon these structures and it is supported by the

nasal skin, the ligaments, and the cartilage as aunit. The nasal bones are the superior limit of thenasal aperture and laterally and inferiorly are

Alveolar process

Mandiblebody

Base of mandible

Mandible angle

Ramus ofmandible

Coronoidprocess

Condylar process

Mental foramen

Fig. 12 Mandible. The mandibular angle is behind and below the inferior third of the molar tooth

NasionIncisura supraorbitalis

Facial zygomaticforamen

Alveolar processof the maxilla

Infraorbitalforamen

Fig. 13 Nasion,supraorbital notch, and theforamens

Facial Anatomy View for Aesthetic Fillers Injections 11

limited by the maxillaries. The nasal cavities aredivided by the nasal septum; the anterior septumportion is formed by the cartilage and the posteriorby the ethmoid and vomer bones. At the lateralwalls of the nasal cavity, we find three to fourcurves of the bones: the turbinates; and the spaceunder each one is defined as nasal meatus. Theanterior nasal spine is found at the median area ofthe inferior border of the pyriform aperture(Fig. 14).

The nasal bones articulate superiorly to thefrontal bone and laterally to the frontal processof the maxillaries and the inferior borders that jointhe nasal cartilage.

Maxilla

Both maxillaries form the maxilla, and its growthis responsible for the vertical elongation of theface between 6 and 12 years. During the agingprocess, bone absorption occurs at a lower degree,and the gravity and absorption of the fat of themalar region are mostly responsible for thedescent of the face.

The maxilla sinus is located at the maxilla; thezygomaticus process extends laterally and articu-lates to the zygomaticus bone; the frontal process(superior direction) joins the frontal bone; thepalatine process (horizontal) joins the oppositeside (forms the palatine skeleton); and the alveolarprocess surrounds and supports the teeth. Its pyra-midal shape with a nasal side or base forms the

lateral wall of the nasal cavity; the orbital sideconsists of the orbit floor; the infratemporal sideforms the anterior wall of the fossa infratemporalis; the anterior side is covered by thefacial muscles.

The infraorbital artery and nerve emergeabout 1 cm under the infraorbital margin acrossthe anterior surface of the maxilla at theinfraorbital foramen (sometimes multiple). Thisforamen is mostly localized at an imaginary lineof the limbus (Fig. 13). The upper teeth areimplanted at the alveolar process of the maxilla.The inter maxilla suture is the point of junctionbetween both maxilla, and the maxilla portionthat supports the incisor teeth is calledpremaxilla.

Mandible

The mandible, or the inferior maxilla, is the big-gest and strongest bone of the face. The inferiorteeth are located at the alveolar part of the mandi-ble. Under the second premolar tooth, the mandi-ble has a mental foramen from where the mentalnerve and vessels emerge, and it is also localizedat an imaginary line of the limbus as a refer-ence to locate the foramen for anesthetic block-age. The mandible has a U shape with a pair ofbranches. The joint area behind and under theinferior third of the molar tooth is described aspart of the branch and for others as a part of thebody (Fig. 11). In this area, the mandible anglepresents a medium value of 125� varying between110� and 140�.

The greatest prominence directed laterally iscalled gonion, and the mental symphysis is themedial area of the mandible. The inferior mandi-ble is the basis, and the digastric fossa is an irreg-ular depression at the basis or near the symphysis.At about 4 cm anteriorly to the mandible angle,the basis can present a sulcus where the facialartery lays and pulsates. The lateral branch of themandible where it turns to be flatter is where themasseter muscle inserts.

The alveolar portions of the mandible sufferserious reabsorption during the years leading toteeth loss, and these effects reflect at the aging of

Nasal anteriorspine

Nasal meatus

Nasal turbinates

Fig. 14 There are three or four curved plaques (conches orturbinates) at the lateral walls of the nasal cavity

12 B. Tamura

the inferior third of the face. The mandible isreabsorbed and becomes thinner and narrower,resulting in an impression of the face fallingdown, worsening the prejaw area and leading toloss of facial contour. Although these areas havegreat importance, we cannot forget the bone lossat the orbit, the temporal area, the facial area, andthe zygomatic arch as shown in Fig. 15 of thecranium and in Fig. 16 that shows the mandiblein different ages.

Temporalis

The temporalis bone is divided as pars squa-mous, tympanic, styloid, mastoid, and petrosal.The squamous and mastoid pars are those ofmost interest and we can describe them in detail.The squamous part of the parietal bone joins infe-riorly to the pars squamous of the temporalis(squamous suture). At the squamous portion, the

zygomaticus process (the zygoma) projects ante-riorly to join to the zygomatic bone completingthe zygomaticus arch. The superior border of thezygomaticus arch corresponds to the inferior cere-bral hemisphere where the temporal fascia inserts.The masseter originates from the inferior borderof the deep surface of the arch. The lateral liga-ment of the temporomandibular junction inserts atthe tubercle of the zygomatic root (inferior borderof the arch) and posteriorly to the tubercle of thehead of the mandible localizes at the mandibularfossa.

The external acoustic meatus (behind the headof the mandible) has in its interior the tympanum(tympanic membrane) with approximately 3 cmof length. The roof and the adjacent posterior wallof the acoustic meatus are formed by the squa-mous part of the temporalis, and the wall isformed by the tympanic part.

The posterior part of the temporalis bone is partof the mastoid and joins the squamous portion. It

Fig. 15 Aging of the cranium

Fig. 16 Aging of the mandible

Facial Anatomy View for Aesthetic Fillers Injections 13

is formed by the mastoid process with an inferiorprojection, and the mastoid process of the twosides of the head is lined with the magnum fora-men. Each process results in insertion into manymuscles. The anterior part of the mastoid processis separated from the tympanic plaque through thetympanic-mastoid fissure that might act as a path-way to the auricular branch of the vagus nerve.

Fossa Temporalis

The temporal line (where the temporal fasciajoins) begins at the zygomaticus process of thefrontal bone forming an arch in a posterior direc-tion through the frontal and parietal bones. Theposterior part joins the supra mastoid crest of thetemporal bone. The temporal fossa, where thetemporal muscle is accommodated, is localizedbetween the temporal line and the zygomaticusline. The origin of the muscle occurs at its floorand has a pars parietal, frontalis, major wing of thesphenoid, the squamous pars of the temporalis,and the place where the four join is called pterion.It lies at the anterior branch of the meninges arteryon the medium side of the cranium and corre-sponds to the surface of the lateral sulcus of thebrain. The center of the pterion is about 4 cmabove the medium part of the zygomaticus archalmost at the same distance behind thezygomaticus process of the frontalis.

The temporal muscle and the deep nerves andvessels cross the space between the zygomaticusspace and the rest of the cranium, and where thetemporalis fossa communicates with theinfratemporal fossa below. The infratemporalfossa lies behind the maxilla, the temporal fossastays medial, and the roof of the fossa is formed bythe infratemporal surface of the major wing of thesphenoid. The medial limit of the infratemporalfossa is the lateral lamina of the pterygoid processof the sphenoid and the lateral is the branch andcoronoid process of the mandible. The lateral andmedial pterygoid muscle, the maxilla artery andits branches, and the pterygoid venous plexus arefound at the inferior region of the temporalis. Themandibular nerve, maxilla, and tympanic cord arealso part of it. The maxilla has a connection with

the orbit through the inferior orbit fissure and itcontinues with the pterygoid maxilla fissure. Inaddition, its connection to the pterygoid maxillafissure offers an intimate relationship with themaxilla artery and nerve at that location (belowthe apex of the orbit).

Description of the Main Facial Muscles

The facial muscles are important when we discussfillers and aging process. Dynamic muscles arerelated to the behavior, durability, and may-be migration of the fillers injected in the face.The facial muscles details are described inthe anatomy of the botulinum toxin chapter. (Seechapter ▶ “Facial Anatomy View for AestheticBotulinum Toxin Injection”).

The frontal muscle with the frontal and occip-ital belly inserts at the aponeurotic galea. At theforehead, they are separated in pairs and areinvolved by the superficial fascia. The frontalmuscle’s function is to elevate the eyebrow andcreate hyperkinetic frontal lines (Fig. 17).

The corrugators muscle originates from theinternal and anterior portion of the superior andmedial orbital margin above the nose and insertsto the frontal muscle and the eyebrow skin. Itscontraction brings the eyebrow together as well aspulls down the glabellar wrinkles (Fig. 17).

The procerus muscle originates from the nasalbone at the glabella and inserts at the skin of theforehead. This muscle pulls down the eyebrowand is responsible for the transversal lines at theglabellar area (Fig. 17).

The orbicularis oculi muscle pars palpebraloriginates from the medial palpebral ligamentand adjacent bone on the medial side of theorbit. The orbital pars comes from a slip of boneadjacent to the orbit on the orbital process of thefrontal bone to the frontal process of the maxilla,and to the medial palpebral ligament between thetwo bony areas (Figs. 2 and 18) and it joins thetransversal nasal muscles. It is a circular musclethat acts as a sphincter. The lateral orbicular oculipulls down the eyebrow.

The temporal muscle has two parts: superficialand deep. The superficial temporal originates

14 B. Tamura

from the fossa temporalis and the temporal fascia,and the deep temporal pars originates from thesphenoidal tubercle. It inserts at the margins ofthe medial side of the coronoid process and at thetemporal crest of the mandibular. It elevates andcontracts the mandible.

The medial and the lateral pterygoid muscle(superior and inferior branch) are located inthe infratemporal region. The superior branchof the lateral pterygoid muscle originates fromthe lateral side of the lateral lamina of the pter-ygoid process and the infratemporal side of themajor wing of the sphenoid bone and insertsat the capsule and the temporomandibularjoint. The inferior branch of the lateral sideof the lateral lamina of the pterygoid process,the pyramidal process of the palate bone, andthe maxilla tuber insert at the pterygoid fovea.Their function is protracting, moving side toside, stabilizing the articular disc, and openingthe mouth. The medial pterygoid muscle origi-nates from the medial side of the lateral laminaof the pterygoid process, pterygoid fossa, pyra-midal process of the palatine, and the maxilla

tuber inserting to the medial side of the mandi-ble, and its function is to elevate the mandibleand act synergistically with the massetermuscle.

At the infraorbital, zygomatic and cheekregion, we find the following muscles.

The orbicularis oculi muscle (pars inferior ofthe orbit), which closes the lids and squeezes themagainst the eyes and originates from the lacrimalbone, the frontal process of the maxilla and skinaround the orbit. The levator labii superioris andalae nasii (Fig. 18) is responsible for the elevationof the upper lid, and the nasal alae also partici-pates to dilate the nostrils and originates from thefrontal process of the maxilla inserting at thesuperior nasal alae. The zygomaticus musclepulls superiorly and posteriorly the upper lip,originates from the body of the zygomaticusbone, and inserts at the superior lip, and thezygomaticus major muscle (Fig. 18) pulls theangle of the mouth superiorly and posteriorlyoriginating from the temporal process of thezygomaticus bone and inserting at the mouthangle (Haddock et al. 2009).

Procerus m.

Orbicularisoris

Corrugators m.

Frontalismuscle

Superficial fascia

Orbicularisoris

Corrugators m.

Frontalismuscle

Superficial fascia

Procerus m.

Fig. 17 Frontal superficial fascia and frontal, corrugators, procerus, and orbicularis oris muscles

Facial Anatomy View for Aesthetic Fillers Injections 15

The risorius muscle slightly pulls (Fig. 19) theangle of the mouth to a posterior position. Itoriginates from the parotideomasseteric fasciaand inserts at the angle of the mouth. The muscle

that elevates the angle of the mouth is the leva-tor anguli oris (Fig. 20). The platysma musclestretches and pulls the neck skin and pulls laterallyand posteriorly the angle of the mouth. The buci-nator muscle emerges posteriorly in thepterigomandibular raphe, and it is responsiblefor pulling laterally and posteriorly the mouthangle and for keeping enough tension in thecheeks during mastication, suction, and whistling.It originates from the vestibular alveolar processof the maxilla at the molars, the maxillae tuber,pyramidal process of the palatine, pterygoid ham-ulus, pterigomandibular ligament, and the vestib-ular face of the alveolar process of the mandible atthe molars area and inserts at the mouth angle. Thebucinator muscle is located posteriorly in the buc-cal fat pad and extends anteriorly to fixate at theoral orbicularis. Finally, the masseter muscle(Figs. 17 and 20) at the parotideomasseteric areahas a superficial and a deep portion. The superfi-cial originates from the inferior border of theanterior two-thirds of the zygomaticus arch, andthe deep pars originates from the internal surface

Levatorlabii m.

Zygomaticusminor m.

Zygomaticusmajor m.

Masseter m.

Orbicularis oris m.

Masseter m.

Zygomaticusmajor m.

Zygomaticusminor m.

Levatorlabii m.

Orbicularis oris m.

Fig. 18 The levator nasal alae and buccal angle muscle

Fig. 19 Risorius and platysma muscles

16 B. Tamura

of the posterior third. It inserts at the lateral branchof the mandible and elevates the mandible.

At the nasal region, the nasal muscle inserts at thenasal alae, dilating the nostrils, and the transversalpars of the nasal dorsum compresses the nostrils(Fig. 21). The nasal septum depressor (Fig. 22) isthe one that shortens the superior lip and depressesthe tip of the nose with the smiling mimics.

At the lips area, the orbicularis oris (Figs. 17and 22) lies very superficially around the buccal

rim. It inserts at the skin and the lips mucosaeacting as a sphincter, and with other local mus-cles intimately associated, it elevates, pullsdown, and holds back the lips combining highlycomplex movements during its normal function.The incisor muscles are tiny muscular fascicles,and they are responsible to squeeze the lipsagainst the teeth, projecting the lips anteriorly andclosing them. The levator of the labial area includesfrom the medial to the lateral zone, the labia

Levatoranguli oris m.

Levatoranguli oris m.

Masseter m.Masseter m.

Platysma m.Platysma m.

Fig. 20 Masseter and levator anguli oris muscle

Dilator nasi m. Dilator nasi m.

Labii and alalevator m.

Nasal m.

Labii and alalevator m.

Nasal m.

Fig. 21 Nasal and nasal dorsum transversal muscle

Facial Anatomy View for Aesthetic Fillers Injections 17

superioris and the alae levator, the labia superiorislevator, the major and minor zygomaticus, therisorius and the depressor, the anguli oris depressor,labia inferioris depressor, and the mentual muscle.The commissures are pulled down by the angulioris depressor and platysma. The laxity of theSMAS at this area creates the so-called marionettelines during the aging process.

At the mental area, the depressor anguli orisoriginates from the basis of the mandible (firstmolar at the mental tubercle) and inserts at themouth corner; the depressor labia inferiorisoriginates from the mandible basis (superior tothe origin of the anguli oris depressor) andinserts at the inferior lip. The mentual muscle

originates from the mental fossa (superiorly tothe mental tubercle) inserting to the chin,everts, and helps to pucker the inferior lip(Fig. 23). The mentual muscle contraction pro-trudes the inferior lip and originates below thecentral and lateral incisor inserting at the mentalskin, wrinkling it.

Sensitive Innervation of the Face

The sensitive innervation of the face is a specialtarget when leading with anesthetic blockage forsurgery or fillers to avoid occlusive complicationsat the foramens when performing treatments with

Mentual m.

Depressorlabii inferioris m.

Depressoranguli oris m.

Depressoranguli oris m.

Depressorlabii inferioris m.

Mentual m.

Platysma m. Platysma m.

Fig. 23 Chin area muscles

Orbicularis oris m.

Depressorseptum m.

Nasal m.Nasal m.

Orbicularis oris m.

Depressorseptum m.

Fig. 22 Depressor nasal septum muscle

18 B. Tamura

implants (see chapter ▶ “Facial Nerve-BlockAnesthesia in Cosmetic Dermatology”).

Forehead

The forehead and the anterior portion of the scalpare innervated by the supratrochlear and supraor-bital nerve (Figs. 24 and 25). The supraorbitalnerve is responsible for the anterolateral portionof the forehead and the scalp’s sensitive

innervation. It emerges between the medial andcentral margin of the superior border of the orbitto the superior and lateral inner surface of thefrontal and galea fascia.

Eyelids

The superior palpebrae and its conjunctiva areinnervated by the ophthalmic nerve. The cornea,the ocular globe, and the dura mater of the

Supraorbital n.

Supratrochlear n.

Supraorbital n.

Supratrochlear n.

Fig. 24 Sensitive innervation of the frontal area

Supraorbitalforamen

Supratrochear n.projection

Supraorbitalforamen

Supratrochear n.projection

Fig. 25 Supraorbital foramen and the projection of the supratrochlear nerve

Facial Anatomy View for Aesthetic Fillers Injections 19

cerebellar tent are innervated by the ciliary nerveand the frontal, ethmoidal, and sphenoidal sinusby the supraorbital and ethmoidal nerve. The lac-rimal gland is innervated by the lacrimal nerveand its palpebral branch that is localized at thesuperior orbital rim (Fig. 26). The lateral areas ofthe inferior palpebrae and its conjunctiva, thelateral area, and the vestibule of the nose areinnervated by the maxilla branch. The infraorbitalnerve and its vascular branch emerge from theinfraorbital foramen to innervate the skin and theinferior lid (Fig. 27).

Nose

The nasal area must be analyzed separatelyconcerning sculpture with fillers. The nasal dor-sum is innervated by the infratrochlear, dorsalnasal supraorbital, and anterior ethmoidal nerves.The septal mucosa and the superior area of thenose are innervated by the anterior ethmoidalnerve. The supratrochlear nerve (trigeminalbranch) emerges from the orbit between the peri-osteum and the orbital septum at the medial supra-orbital margin and innervates the medial and

central area of the forehead and the nasal radix.The external nasal nerve is a branch of the anteriorethmoidal nerve (trigeminal nerve) and innervatesthe dorsum, apex, and the nostrils. The externalnose is innervated by the infraorbital nerve (local-ized deeply through the central massif bone of theface) that has also a sensitive innervation of themaxilla area.

Auricle-Temporal, Cheek, Mandible,and Maxilla Areas

The auricle-temporal nerve originates from themandibular branch of the trigeminal nervedirecting posteriorly surrounding the meningealmedia artery and then contouring the mandibleneck to the temporal area in an ascendant trajec-tory crossing the temporomandibular joint, theauricle pinna, the external acoustic meatus, thetympanic membrane, and the parotid gland inner-vating the auricle-temporal, the mandible, andmaxilla area. The great auricular nerve is at thecervical fascia, posteriorly to the mandible angle;the posterior auricular nerve that is a branch of thefacial nerve, and innervates the external acoustic

Fig. 26 The palpebral branch of the lacrimal nerve locates at the lateral superior orbital rim

20 B. Tamura

meatus skin and the ear pavilion. The magnumauricular nerve innervates the skin of the parotidgland. The nerve of the tympanic cord is a branchof the facial nerve that originates from thisarea through the petro-tympanic cleft. Thezygomaticus-facial nerve (branch of the trigemi-nal nerve) that externalizes through the foramen ofthe same name, innervates the skin of the zygo-matic area, and finally, the mandibular branch ofthe facial nerve that crosses the medial and ante-rior portion of the mandible. This nerve is local-ized most of the times at the angle of the mandibleat the medium lateral zone. The pterygopalatineand nasopalatine nerves complete the maxillaarea. The nerve that is responsible for the para-sympathetic innervation of the parotid gland is theoptic ganglion localized at the medial area ofthe mandibular nerve branch near the oval fora-men (Goldberg 2009; Altruda Filho et al. 2005;Gardner et al. 1978; Tamura 2010a, b).

Buccal Area

At the buccal area, we need to take into accountnot only the buccal area, the peribuccal, and the

cheek, but also the internal area of the mouth andthe alveolus as they are intimately related. Thebuccal nerve is one of the branches of the man-dibular nerve of the trigeminal nerve that crossesthe adipose body of the cheek after crossing theinfratemporal fossa. It is responsible for the muco-sal, cheek skin, and the inferior vestibular molarmucosa sensitivity.

The terminal branches (labia superioris) of theinfraorbital nerve are responsible for the superiorlabial skin and mucosa and the mentum (theyemerge from the mental foramen below the sec-ond inferior premolar) through the skin and theinferior labia mucosa and the chin region. Themandibular branch has sensitive (sensorialbranch) and motor (motor branch) functions. Themucosa, the inferior lip’s skin, the mentum, theanterior portion of the tongue, and the mouth floorare innervated by the mentum and tongue nerve.The buccal mucosa and the skin of the cheeks areinnervated by the buccal and auricle temporalnerve.

The superior incisor, maxillary sinus, nasalcavity, and the gingiva are innervated by the alve-olar superior medial branch. The inferior alveolarbranch innervates the molar tooth, the gingiva of

Infraorbital n.

Parotid duct

Infraorbital n.

Parotid duct

Fig. 27 Terminal branch of the infraorbital nerve and vessels emerging from the infraorbital foramen to innervate theinferior lid and the local skin

Facial Anatomy View for Aesthetic Fillers Injections 21

the superior molar area, the buccal mucosa, andthe maxilla sinus. The inferior alveolar nerve orig-inates from the mandible nerve and continues nextto the deep layer of the lateral pterygoid musclethan between the medial and lateral pterygoidmuscle, directs inferiorly through the medial faceof the mandible branch penetrating the mandibleforamen, crosses the mandible canal, and emitsdental branches to the molars and inferior premo-lars. At the mental level, it originates the mentalnerve (Fig. 11) (innervates the soft tissue of thementum, the mandible, the inferior labia, vestibu-lar gingiva of the incisors, canines, and inferiorpremolars) and the incisor nerve (innervates theincisors, canines, and their respective peri-odontium). It directs anteriorly, inferiorly, andmedially to the inferior alveolar nerve and itsfibers go with the tongue nerve and distributewith it. It provides afferent fibers to the tastebuds at the anterior two-thirds of the tongue andefferent visceral parasympathetic fibers to the sub-mandibular, sublingual, and tongue glands.

The tongue nerve originates from the mandiblenerve, locates anterior and medial to the inferioralveolar nerve, and crosses between the medialand lateral pterygoid. At the posterior extremityof the milo-hyoid line, the tongue nerve directs tothe oral cavity. This nerve is responsible for thegeneral sensibility of the anterior two-thirds of thetongue, sublingual mucosa, and lingual gingiva ofthe inferior teeth of the submandible and sublin-gual glands.

Motor Innervation (Facial Nerve)

The origin of the motor nerves of the face is thefacial nerve and its branches. When we injectfillers at the pretragus area, it is important toremember that at the deep layer of the subcutane-ous, the injection must be very delicate and slow,avoiding inserting the needle numerous times atthe same place. In addition, we must prevent highlocal volume injection to avoid pressureparesthesia.

The temporal nerve (Fig. 27) leaves the parotidand crosses the zygomaticus arch (intermediateportion) where it becomes superficial and

susceptible to trauma or irreversible lesions inminimally invasive procedures. It does inner-vate the eyebrows, the frontal area, the eyelid,anterior and superior auricular muscle, and thefrontal venter of the epicranius muscle. Thesafest layer for dissection or invasive proce-dures is at the subcutaneous or deep temporalfascia. The anterior and posterior temporalnerve are responsible for the motor innervationof the temporal and the posterior muscle cap-tures the proprioception or the temporomandib-ular capsule of its joint.

The frontal branches of the facial nerve arelocalized in the temporoparietal fascia, atthe medium portion of the zygomaticus arch. Itis responsible for the motor innervation of thefrontalis, corrugators, procerus, and the cephalicportion of the orbicularis oculi muscles.

The infratemporal area nerves are the masse-teric, the deep temporal, the buccal, the inferioralveolar, the lingual, the auricle-temporal, thetympanic chord, and the optic ganglion. Themandibular nerve originates the buccal, and itdirects laterally between the lateral pterygoidmuscle fibers and continues anther-posteriorlyand medially to the deep temporal muscle fibers.It runs across the adipose body of the cheek anddistributes its fibers to the skin and mucosa of thecheek and the vestibular gingiva of the inferiormolars (sometimes of the superior molars). Theinferior alveolar nerve goes down passing nearthe deep area of the lateral pterygoid muscleand then between the medial and lateral mus-cles. It directs inferiorly through the medialregion of the mandible branch, enters into themandible foramen, crosses the mandible chan-nel, and subdivides in dental branch for themolars and inferior premolars. When overcom-ing the mental foramen, it originates the mentalnerve (innervates the soft tissues of the chin andthe inferior lips, vestibular gingiva of the inci-sors, canines, and inferior premolars) and theincisor nerve (innervates the incisors, canines,and their respective periodontium) (AltrudaFilho et al. 2005).

The zygomaticus and buccal branches of thefacial nerve are localized at the medial and mostsuperficial part of the cheek. The zygomaticus

22 B. Tamura

innervates the inferior bundle of the orbicularisoculi and the buccal nerve (Fig. 28), and is respon-sible for the nasal area through the levator labiasuperioris and the nasal, procerus, risorius,bucinator, superior portion of the mouthorbicularis, and the nasal pars alar and transversalmuscle. This nerve passes more superficially atthe zygomaticus arch and we need to inject fillersvery delicately and every time we inject a greateramount. We need to observe and take into accountparesthesia complaints to avoid complications.

The motor nerves at the parotideomassetericarea are the terminal branch of the facial nerveand are originated from the intra parotid plexus(temporal, zygomaticus, buccal, mandible mar-ginal, and cervical branch); the posterior auricularnerve innerves the occipital venter of theoccipital-frontal and auricular posterior branch,the stylohyoid innervates the stylohyoid muscle,and finally the digastric branch innervates theposterior venter of the digastric muscle.

The pterygopalatine nerves that should beremembered are the infraorbital, the zygomaticus,

posterior superior alveolar, pterygopalatine,nasopalatine, and the pterygopalatine ganglion.The buccal branch is the motor nerve for thesuperior lip and the marginal of the mandible forthe inferior lips and are considered to be at highrisk for traumas and complications in slimpatients. The sensitive innervation of the superiorlip depends upon the infraorbital nerve and theinferior lip on the mental nerve, emerging fromthe infraorbital and mental foramen. The buccalbranch is responsible for the motor innervation ofthe mouth orbicularis, and the muscle that actsaround the mouth is innervated by the buccalbranch and the marginal of the mandible(Figs. 27 and 28). Therefore, we need to be carefuland delicate when products are injected around2 cm lateral to the buccal angle where the nervebecomes a little superficial, exposed, and is sus-ceptible to traumas (Gardner et al. 1978).

The mandible marginal nerve (origin of thefacial nerve) is responsible for the motor innerva-tion of this area and crosses the parotideo-masseteric and the cheek area. The superficial

Fig. 28 Vascularization of the temporal, zygomaticus, and mandibular area

Facial Anatomy View for Aesthetic Fillers Injections 23

mandible marginal nerve is deeper to the platysmaand is located around 1–2 or 4 cm below theinferior border of the mandible, but as it reachesthe mouth, directs superficially and enters at thedepressor muscle. This muscle trauma leads toincapability to depress the mouth, the buccalbranch until the bucinator muscle, and the damageof the branch that ends at the orbicularis muscleleads to incapability to elevate the mouth angle.

Facial Vasculature (Altruda Filho et al.2005; Gardner et al. 1978; Tamura2010a, b)

The external carotid is responsible for facial irri-gation, and its main branches are the thyroid,lingual, facial, occipital, posterior auricularartery, maxilla, and superficial temporal artery(Fig. 29).

From these, the one that we study mostly is thefacial artery and its branches but the most impor-tant issue will be discussed below. The trajectory

of this artery extends from the external mandiblesurface under the platysma until the medial angleof the eye. The facial artery crosses the bucinatorand maxilla muscle, deeply to the zygomaticusmajor and the levator labia superioris. The facialartery divides into lips and lateral side of thenostrils branches. The angular artery is part ofthe facial artery that runs along the nose until themedial angle of the eye to irrigate the lids.

The largest branch of the external carotid is themaxilla artery that divides into three branches: thedeep auricular with branches for the externalacoustic meatus; the tympanic for the tympanicmembrane; and the meningea alveolaris to thegingiva and teeth. The second part with the mas-seteric, deep temporal, pterygoid, and buccalbranches. The branches for the third part are thesuperior-posterior; superior media alveolar arter-ies; infraorbital; descendant palatine; pterygoidchannel; and pharyngeal and sphenopalatinearteries.

The superficial temporal artery is a terminalbranch of the external carotid and originates

Orbicularis n.

Temporalis n.

Zygomaticfacial n.

Buccal n.

Mandiblemarginais n.

Mandiblemarginais n.

Orbicularis n.

Temporalis n.

Zygomaticfacial n.

Buccal n.

Fig. 29 Branches of facial nerve

24 B. Tamura

at the parotid gland, runs up to a superficial layerto the posterior part of the zygomaticus process ofthe temporalis bone until the mandible cleavage.It continues upward and crosses anteriorly tothe external acoustic pore 2–3 cm above thezygomaticus arch. It irrigates the temporal, fron-tal, parietal, the duct, and the parotid glandthrough the branches with the same name,respectively. At the temporal area, the mainvein is the superficial temporalis that drains thetemporal, frontal, and parietal areas. The lateraland medial pterygoids muscles are nourished bythe pterygoid branches of the posterior deeptemporalis. The main vein of this region is theretromandibular (maxilla and superficial temporalisvein) that are located near the mandible cleavagegoing downward into the parotid gland. At the tem-poral zone, the veins are a tributary of the pterygoidplexus.

The infratemporal area is irrigated by thefollowing arteries: middle meningeal; deep ante-rior and posterior temporalis; superior, posterior,and inferior alveolar; infraorbital; masseteric;mylohyoid; buccal and lingual arteries. The mid-dle meningeal irrigates the dura mater and theadjacent bone and the superior posterior alveolarartery penetrates into the tuber of the maxillathrough the alveolar foramen; it irrigates themolars and superior premolars teeth through thedental branches and the alveolar process, peri-odontium, and vestibular gingiva through theperiodontal branches. The inferior originatesfrom the same region of the middle meningealartery but directs to the mandibular foramen andbefore penetrating into the mandible channel ram-ifies in mylohyoid artery that irrigates themylohyoid muscles and the anterior venter of thedigastric muscle. The infraorbital artery originatesfrom the pterygoid maxilla cleft (near the maxillatuber) penetrating the orbit toward the facethrough the infraorbital foramen and the terminalbranches irrigate the soft tissue of the mediumthird of the face (inferior lid); the external noseand the superior lid. The masseteric artery origi-nates from the lateral pterygoid muscle area pass-ing laterally through the mandibular notchirrigating the masseteric muscle and the capsuleof the temporomandibular joint.

The buccal artery originates near the deep tem-poral anterior artery, follows a lateral inferiordirection to the jugal area, irrigating the cheekand the bucinator muscle. The lingual artery (orig-inates from the external carotid) directs to thehyoglossus muscle to ramify and irrigate thetongue muscles, the post sulcus part of the dorsumof the tongue, the floor of the mouth, and thesublingual gland. The veins of the infratemporalarea form the pterygoid venous plexus that receivethe blood from the deep face draining to the max-illary veins.

The supraorbital artery (Fig. 30) is a terminalbranch of the ophthalmic artery that originatesfrom the internal carotid artery. At the infraorbital,zygomatic, and cheek the lacrimal artery exterior-izes at the lateral region of the orbit and anasto-moses with the transversal facial artery (firstbranch of the superficial temporal artery). Thetransversal facial artery originates from the super-ficial temporal before emerging from the parotidgland and crosses the face superficially to themasseter muscle and divides into several branchesthat irrigate the parotid gland, its duct, the masse-ter duct, and the facial skin. There are also termi-nal branches of the infraorbital artery (inferiorpalpebral, superior labial, and nasal) that origi-nates from the infraorbital foramen. The branchesof the facial, buccal, and alveolar superior andposterior are also important for the irrigation ofthis area. The tributary veins of the facial, super-ficial temporal and pterygoid, and the superior-external part of the maxilla area have a deepvenous complex that must be avoided when thepatient is treated with fillers.

At the parotideomasseteric area, the mainartery is the external carotid that directs upwardbetween the styloglossus and the stylohyoid mus-cles and penetrates in the parotid gland. Its termi-nal branch is the temporal artery penetrating at theparotid gland.

The facial artery is basically the main arterythat irrigates the labial and nasal area. The facialarteries are extremely tortuous and the techniquesfor injecting fillers in various layers and directionsto get natural lips volume leads to a predicablearterial perforation with much more hematomasand ecchymosis as adverse events. The angular

Facial Anatomy View for Aesthetic Fillers Injections 25

artery is a terminal branch of the facial artery thatirrigates the lateral area of the dorsum near theradix of the nose crossing the levator labii super-ioris and the nostrils, and because of the charac-teristics and extension of the nourished area, it hasimportance when we consider the consequencesof its occlusion due to injection, spasms, or com-pression leading to necrosis and ischemia. Thebranch of the columella and the nasal lateralbranch irrigate the nostril, the dorsum, and theapex of the nose (tip of the nose). The dorsalnasal artery (irrigates the radix and nasal nostrils,and one of its branches that unites with the angularartery at the nasal radix and the other goes downfor the external nasal anastomosis) is the branch ofthe infraorbital branch. The nasal lateral veins areat 2–3 mm over the alar sulcus, and with thecolumella artery emerge deeply at the nasal basisand end at the tip of the sub dermic plexus. Theyare tributaries of the angular vein that drains theexternal nose.

The arteries that irrigate the lips are the supe-rior and inferior labia artery (branches of the facialartery), and they anastomose with the oppositeside forming an arterial circle around thebuccal rim.

At the mental area, the most important arteriesare the submental and the mental. The submentaloriginates at the facial artery at the submandibulararea; passes through the mandible basis until the

chin; and irrigates the mylohyoid muscle, theanterior venter of the digastric artery and the adja-cent structures. The chin is also irrigated by themental artery that is a branch of the inferior alve-olar artery that emerges through the mental fora-men. The venous drainage corresponds to thearterial supply. The mandible is irrigated by thefacial and alveolar inferior artery (Sykes 2015).

About the Retinal Blood SupplyThe central retina artery is a branch of the oph-thalmic artery, and the major origin is the internalcarotid artery. The central artery passes throughthe optical nerve and disc dividing into temporalsuperior and inferior branch and nasal superiorand inferior branch. Although having anastomo-ses between the ciliary arteries, the branchesdescribed anteriorly should not have anastomo-ses between them or other arteries; thus, areconsidered terminal arteries (without any anasto-moses between arterioles and venules) and con-nection between them occurs only through thecapillary system, and the central artery occlusionresults in amaurosis. The retina veins run withthe arteries and drain at the cavernous sinus(Figs. 31 and 32). Some interesting reports tryto explain the central artery occlusion’setiopathogeny after fillers injections in the gla-bellar area, and there are several reports of amau-rosis after fillers injections due to the reversal

Supraorbital a. Supratrochlear a. Supraorbital a. Supratrochlear a.

Fig. 30 Vascularization of the frontal area

26 B. Tamura

influx, and anastomosis between internal andexternal carotid arteries supporting this terriblecomplication. According to Arletti and Trotter(2008), we could understand that fillers injectiontechnique must be reviewed and it justifies thereason for so many reports of vascular occlusionand necrosis. Fig. 33 shows that the 27G needleis far thicker than the dermis between the cheekand the nostril. It is crucial to understand that thedermis thickness varies between patients andalso different areas of the face. Fig. 34 showsthe frontal dermis thickness of one patient thatcan also vary depending upon the age, photo-damage, and ethnicity, and we must be aware ofthis to improve our techniques and minimizearterial occlusion risk.

The retina central artery is a branch of theinternal carotid artery and any thrombi mightlead to blindness after an intra-arterial fillers injec-tion at the periocular area. The palpebral veinsdrain to the angular (Fig. 34), ophthalmic, and

superficial temporal veins. The angular and oph-thalmic veins anastomosis drains the blood fromthe medial palpebral area skin and lateral nasal tothe cavernous sinus where intracranial infectionmight occur (Alam and Dover 2007; Alam et al.2008; Glogau and Kane 2008; Goldberg 2009;Hirsch and Stier 2008).

There are also reports about possible anasto-moses between the internal and external carotid atthe intranasal area leading to amaurosis, for exam-ple, the ophthalmic area, but there are still issuesto be understood about the vascular irrigation ofthe face and occlusion after implant injections.

Lymphatic System

The lymphatic drainage of the face occurs in aposterior and inferior direction. The medial area(including the upper and lower lips) drains to thefacial, submental (including central area of

Cavernous sinus v.

Middlecerebral a.

Oculomotor n.

Optic n.Ophthalmic a/v.

Communicant a.

Fig. 31 Intimal relationship from the ophthalmic and the middle cerebral artery

Facial Anatomy View for Aesthetic Fillers Injections 27

the lower lip), and submandible lymph nodes; thelateral area of the face, frontal area, and the scalpto a diagonal line (infraorbital, zygomatic andcheeks areas) to the parotid lymph nodes.

In our practice, the periocular area frequentlyleads to a drainage complication. Botulinuminjections with too many units or advanced extrainjections might lead to a “puffy” eyes. If we addfillers, sometimes with excessive volume to

correct the upper lid hollow or the inner (and/orlateral) palpebral malar sulcus might evolve intonot only puffy eyes but long-term edema of theeyelids. Combining both, botulinum toxin andfillers, this adverse event might be frequent, asthe palpebral lymphatic system is very delicateand not prepared to undergo trauma or proce-dures. The muscular contraction at this area iskey for a proper local drainage and an excessiverelaxation of the orbicularis oculi muscle surelyleads to its deficiency. The implant pressure at thepalpebral sulcus also presses or occludes the pal-pebral, very sensitive and delicate lymph ductalsystem. Although the lymphatic drainage is usu-ally described as the ocular region as a whole, itshould be divided into a medial and a lateraldirection outflow. To do an efficient manual drain-age with the aim of minimizing the local edema,we should strum the infraorbital area from themedial to the nasal direction and from the lateralto the preauricular area.

The lymphatic vessels of the infratemporalarea drain to the deep superior cervical lymphnodes. The parietal and occipital area of thescalp drain into the parotid lymph nodes anteriorly

Angularis a.

Nasal dorsum a. Angularis v. Nasal dorsum a.

Angularis a.

Angularis v.

Fig. 32 Angular artery and vein and the nasal dorsum artery

Fig. 33 27G needle is thicker than the dermis itselflocated between the cheek and the nostril

28 B. Tamura

and retroauricular lymph nodes posteriorly. Theoccipital area drains into the occipital area lymphnodes and the cervical nodes filters the lymphnode between the face and neck, scalp, andmucosa. At the pterygopalatine area, lymphaticdrainage occurs basically in the retropharyngealand deep-superior cervical lymph nodes.

Take Home Messages

• The vessels, especially at glabellar, ocular,nasal areas, and the terminal arteries, must beavoided due to various reports of arterial occlu-sion, ischemia, and even embolus, leading tosevere complications.

• The thickness of the dermis at the nasolabialfold is below 2mm, and taking into account thebevel and the diameter of the needle, we couldunderstand that fillers injection technique mustbe reviewed.

• Most of the fillers are injected below the dermisand not intradermally, at the level of the artery,

justifying the onset of the many vascular occlu-sions and necrosis reported in the literature.

• The facial arteries are extremely tortuous, andthe techniques for injecting fillers in variouslayers and directions to get natural lips volumeleads to a predictable arterial perforation withmuch more chances of resulting in hematomasand ecchymosis.

• The angular artery is a terminal branch of thefacial artery that irrigates the lateral area ofthe dorsum near the radix of the nose crossingthe levator labii superioris and the nostril mus-cle of the nose. Because of the angular arterycharacteristics and extension of the nourishedarea, we need to consider the terrible conse-quences of its occlusion due to injection lead-ing to necrosis, ischemia, and scars.

• Botulinum injections with too many unitsor advanced extra injections might lead to“puffy” eyes. Sometimes, when we add fillerswith excessive volume to correct the upper lidhollow or the inner (and/or lateral) palpebralmalar sulcus, it might result in not only puffyeyes but long-term edema of the eyelids.

References

Alam M, Dover JS. Management of complications andsequelae with temporary injectable fillers. PlastReconstr Surg. 2007;120(Suppl 6):98S–105S.

AlamM, Gladstone H, Kramer EM, et al. ASDS guidelinesof care: injectable fillers. Dermatol Surg. 2008;34:s115–48.

Altruda Filho L, Candido PL, Larosa PRR, Cardoso EA.Anatomia topográfica da cabeça e do pescoço. 1ª ed.Barueri: Manole; 2005.

Arlette JP, Trotter MJ. Anatomic location of hyaluronicacid filler material injected into nasolabial fold: a his-tologic study. Dermatol Surg. 2008;34:s56–63.

Carruthers J, Cohen SR, Joseph JH, Narins RS, Rubin M.The science and art of dermal fillers for soft-tissueaugmentation. J Drugs Dermatol. 2009;8(4):335–50.

Gardner E, Gray DJ, O’Rahilly R. Anatomia. 4a ed. Rio deJaneiro: Guanabara Koogan; 1978.

Glogau RG, Kane MAC. Effect of injection techniques onthe rate of local adverse events in patients implantedwith nonanimal hyaluronic acid gel dermal fillers.Dermatol Surg. 2008;34:S105–9.

Goldberg DJ. With this filler/volumizing agent nowbecoming available, the interest in non-surgical facialsculpturing will continue to expand. J Cosmet LaserTher. 2008;10(3):133.

Fig. 34 This photo shows the frontal dermis thickness of apatient that might vary drastically between patients

Facial Anatomy View for Aesthetic Fillers Injections 29

Goldberg DJ. Correction of tear trough deformity withnovel porcine collagen dermal filler (Dermicol-P35).Aesthet Surg J. 2009;29(Suppl 3):S9–S11.

Haddock NT, Saadeh PB, Boutros S, Thorne CH. The teartrough and lid/cheek junction: anatomy and implica-tions for surgical correction. Plast Reconstr Surg.2009;123(4):1332–40. discussion 1341–2.

Hirsch RJ, Stier M. Complications of soft tissue augmen-tation. J Drugs Dermatol. 2008;7(9):841–5.

Pessa JE, Rohrich RJ. Topografia facial. Anatomia clinicada face. 1a. ed. Rio de Janeiro: DiLivros; 2012.

Sadick NS, Karcher C, Palmisano L. Facial enhance-ments using dermal fillers. Clin Dermatol. 2009;27:S3–S12.

Sobotta J, BecherH.Atlas deAnatomiaHumana. 17ª. Edição,vol 1 a 3. Rio de Janeiro: Guanabara Koogan; 1977

Sykes JM, Cotofana S, Trevidic P et col. Upper Face:Clinical Anatomy and Regional Approaches with Inject-able Fillers. Plast. Reconstr. Surg. 136: 204S, 2015

Tamura B. Anatomia da face aplicada aos preenchedores eà toxina botulínica. Parte I. Surg Cosmet Dermatol.2010a;2(3):195–204.

Tamura B. Anatomia da face aplicada aos preenchedores eà toxina botulínica. Parte II. Surg Cosmet Dermatol.2010b;2(4):291–303.

Tamura B. Topografia facial das áreas de injeção de pre-enchedores e seus riscos. Surg Cosmet Dermatol.2013;5(3):234–8.

30 B. Tamura