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.