The forgotten facial vessel: Zygomaticofacial artery
The zygomaticofacial artery is often excluded or ‘left out’ of medical textbooks and teaching, yet, when you have been practising medical aesthetics for a little while and you discover its existence, it can make your blood run cold and leave you disconcerted.
In this blog, Dr Tim Pearce will discuss the ‘forgotten artery’ that is the zygomaticofacial artery. Not present in all people, it is perhaps simply deemed less important, yet if you are injecting dermal fillers and want to avoid a complication, like vascular occlusion, then you must understand this little mentioned anatomical feature.
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What is the zygomaticofacial artery?
Clinical papers that mention the zygomaticofacial artery and zygomaticofacial foramen claim that it is only present in approximately one in every three people, which may explain its lack of appearance in many anatomy textbooks.
Although it may be disconcerting to learn of its existence, Dr Tim believes it is because it is probably not clinically important, but it is still nice to know what lurks beneath a face when you are about to inject it, no?
The zygomaticofacial artery is tiny, a branch of the lacrimal branch of the ophthalmic artery, that enters the face through the zygomaticofacial foramen. You can sometimes palpate the foramen to determine its existence, and you may be able to feel a pulse, but this is not a particularly sensitive test, so arguably it is easier to assume your patient has one and consider this when injecting.
Although tiny, often forgotten, and potentially absent, it is an important artery for aesthetic clinicians because we inject very close to it when performing cheek filler treatments.
You may be in this area when treating the lateral lid-cheek junction – blending in the cheek and the eye areas – or as part of a cheek augmentation or tear trough treatment. Often, practitioners are trained to inject in this area, on the bone of the zygoma, when treating cheeks and tear troughs, thus is it vital to understand the potential existence of the zygomaticofacial artery.
Although Dr Tim has not heard about or seen an injury case from direct injection into this artery, that is not to say that it does not occur, as many complications go unreported. Therefore, the potential for injury remains. The zygomaticofacial artery is directly connected to the lacrimal artery and thus the ophthalmic artery, therefore, it is theoretically possible, if you were to inject enough filler product into the vessel, to cause blindness.
This would of course be an incredibly rare event, hence the theorising. In most patients, due to the size of the artery, it would be very difficult to cause a direct hit and to go on to cannulate the vessel and infiltrate significant volume of product. Similarly, if there is a nerve alongside in the foramen, it would result in a reaction of discomfort from the patient long before significant injury could happen to the artery.
Don’t panic if you have never heard of the zygomaticofacial artery
As aesthetic clinicians, we are in a constant battle to build a mental model that gives us the confidence to inject patients and treat them with dermal fillers. Therefore, when you find out there are some fundamental flaws in your model, in a part of the face that you regularly inject, it is rightfully worrying, but by reading this blog you are already on the way to increased learning and away from that fear.
Dr Tim notes that it is a continuous battle. As practitioners of aesthetic medicine, we are always picking up little things about anatomy that you had not quite visualised correctly in your mind, or you discover there is a variant of it in one of your patients that does not match the theory. This is a process you should be on for the whole of your aesthetic career, finding out a little bit of information here and there, improving your mental model, and then adapting your injection technique slightly to reflect your learning.
Consider topping up your anatomical learning with Dr Tim Pearce’s eLearning online courses or investing in a collection of artistic anatomy posters by Dr Tim Pearce for your clinic.
How to avoid the zygomaticofacial artery when injecting
The first test you can do prior to injecting into the cheek is to palpate the area to feel for the presence of the zygomaticofacial foramen. In thinner patients, you may be better able to feel it, and this can act as a guide of where not to inject.
Secondly, if you are using a needle for injection in the area, it is best practice to aspirate. Ideally, if you have a mental model of where the artery might be located, then you can place your needle somewhere either side as your target for treatment, and hopefully secure a negative aspirate.
Ensure you watch the reaction of your patient as you treat this area. If there is a nerve present in the foramen, they will react differently, and this can act as an early warning system of your needle location. Consider moving 4mm to the left or right to avoid the theoretical risk and provide reassurance for both you and your patient.
Finally, you may wish to mitigate the risk by changing your choice of equipment for the injectable treatment. A cannula is probably less likely to cause injury to the zygomaticofacial artery than a needle, especially if you are using low viscosity products with thin needles that would flow more easily if a vessel were to become cannulated, than thicker hyaluronic acid gels. Your product choice may therefore impact on your choice of needle or cannula close to the zygomaticofacial artery.
You can also find Dr Tim Pearce on Instagram if you have any questions or comments about dermal filler treatments and facial anatomy.
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Aesthetics Mastery Show
The Forgotten Artery: Why You SHOULD Know About Zygomaticofacial
In this episode, Dr Tim shows us how to locate the zygomaticofacial artery; how to avoid hitting and occluding it; and the real reason you weren’t taught about it in the first place! Watch the full Aesthetics Mastery Show here.
Read more and join in the debate on our YouTube channel.
Filler Complications eLearning Courses
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In addition, browse our FREE downloadable resources on complications.
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Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.
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