Nov 4, 2018 - (therefore blockage results in tissue necrosis). Benefits of Hyaluronic Acid (HA) Filler Over Other. Types of Fillers. What are Dermal Fillers?
A novel idea in the use of ultrasound to guide nasolabial hyaluronic acid (HA) dermal filler injections to prevent alar nasal necrosis D Klubowicz
1,
M
1 Johnson ,
M
1 Barbeau ,
A Khalil
2,
C
1 Martin ,
P
1 Merrifield ,
1,
H
1 Perinpanayagam ,
2,
Department of Anatomy and Cell Biology Department of Medical Sciences Schulich Dentistry Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
METHODS
BACKGROUND • • •
Soft tissue cosmetic injectables that are usually applied to the face
A.
Dissolvable using hyaluronidase2
•
Temporary (~ 6 months)
•
Non-immunogenic2
Mean
Maxillary Teeth Maxillary Ridge Figure 1: One of the most popular dermal filler areas of application: nasolabial fold or “smile lines” and the area of interest for this project.2
Figure 2. Hyaluronic Acid Dermal filler is sold in pre-packaged 1 mL syringes that cost ~ $802 per syringe.1
Complications
• Individuals have been found to present with necrosis after obtaining HA filler injections into the nasolabial fold
Mean Distance to Skin (cm) – Right
Mean Distance to Skin (cm) – Left
Total
Benefits of Hyaluronic Acid (HA) Filler Over Other Types of Fillers •
B.
Antero-inferior Angle of the Mandible Mandibular Teeth
Restore volume in wrinkles giving the client a more youthful appearance Most popular type of filler globally is hyaluronic acid (Over 2 million Insert Text Here Americans receive these fillers annually)1
3
RESULTS
Part 1: Dissection of the facial artery on 18 hemi-sected heads (8 male, 10 female) to identify artery course and variations.
What are Dermal Fillers?
KA Galil
1,3
0.438 0.481 0.366 0.343 0.409
SD
0.126 0.107 0.144 0.097 0.129
Antero-inferior Angle of the Mandible Mandibular Teeth Maxillary Teeth Maxillary Ridge
Total
Mean
SD
0.417
0.144
0.556 0.451 0.425 0.459
0.124 0.202 0.307 0.205
* Figure 5. A) B) Bilateral dissection of facial artery and branches following up from external carotid, submandibular gland to find at the antero-inferior angle of the mandible. Large amount of variation noted between the 2 bilateral facial arteries. Ie. B) Lacking inferior labial artery, lateral nasal artery, angular artery and an extra branch off of superior labial artery is noted (*).
Part 2: Ultrasound study on living participants examining facial artery width (cm), distance to skin (cm), distance to bone (cm) at 4 specific bony landmarks: antero-inferior angle of mandible, mandibular teeth, maxillary teeth, and maxillary ridge.
Figure 5: Mean distance to skin ( SD) measured at 4 bony landmarks of interest: Antero-inferior angle of the mandible, mandibular teeth, maxillary teeth, maxillary ridge from A) Left side (*P< 0.05 to mandibular teeth) and from B) the right side.
• Necrosis results from intravascular injection causing arterial blockage3 A
B
SUMMARY
C
Figure 3. A)B)C) Necrosis resulting from injection of filler directly into vasculature coursing near the site of injection (nasolabial fold).3
•
Within the limits of this study, the average distance from the surface of the skin to the facial artery at the maxillary ridge has been found to be significantly different from distance to mandibular teeth on the left side.
•
As the number of participants increases we expect to further validate the results.
Anatomy of Facial Artery
• Artery courses very tortuously near or over nasolabial fold (highly variable between individuals)3 • Provides lateral nasal branch that provides the only blood supply to nasal ala (therefore blockage results in tissue necrosis)
FUTURE DIRECTION Figure 6. Demonstration of 13-6 MHz, 38 mm linear array ultrasound transducer placement and position over the antero-inferior angle of the mandible.
Figure 7. Four bony landmarks of interest for ultrasound imaging: Antero-inferior angle of the mandible, mandibular teeth, maxillary teeth, maxillary ridge. B
• Part 3 of study: Use ultrasound to help avoid the facial artery while administering dermal filler injections into the nasolabial folds of fresh frozen cadavers • Expand study to the clinical level and use ultrasound-guided nasolabial hyaluronic acid dermal filler injections on patients
A
ACKNOWLEDGEMENTS Figure 4. Layers of the skin emphasizing the variable Figure 4. Course of the facial artery as it provides superior location of the facial artery. Figure also depicts the possible and inferior labial arteries, lateral nasal artery, angular artery. locations for filler injection.
C
OBJECTIVES • Part 1: Is to describe the distribution of the facial artery in relevance to four bony ultrasound landmarks: antero-inferior angle of mandible, mandibular teeth, maxillary teeth, maxillary ridge • Part 2: To describe the distance to bone, distance to skin, and width of the facial artery relative to bony landmarks that can be identified on ultrasound. Purpose of Study: • Mitigate the potential for arterial occlusion/compression therefore decreasing the risk of devastating complications such as necrosis
• • • •
Dr. Khadry Galil (chief supervisor) Josée Legault Anatomy lab supervisor Haley Linklater and lab technician Kevin Walker Clinical anatomy colleagues
REFERENCES D
Figure 8. A) Ultrasound image of facial artery located over the 2nd mandibular premolar. B) Distance from base of facial artery to 2nd mandibular premolar measured at 0.41 cm. C) Width of facial artery measured at 0.14 cm over the 2nd mandibular premolar. D) Distance from the top of facial artery to the skin measured at 0.43 cm.
1. American Society of Plastic Surgeons. (2016). Plastic Surgery Statistics Report, 125. https://www.plasticsurgery.org/documents/News/Statistics/2016/plastic-surgerystatistics-full-report-2016.pdf 2. Liu, L., Liu, Y., Li, J., Du, G., & Chen, J. (2011). Microbial production of hyaluronic acid : current state, challenges , and perspectives, 1–9. 3. Grunebaum, L. D., Allemann, I. B., Dayan, S., Mandy, S., & Baumann, L. (2009). The Risk of Alar Necrosis Associated with Dermal Filler Injection, 1635–1640. https://doi.org/10.1111/j.1524-4725.2009.01342.x
