Clinical Anatomy (2019)

ORIGINAL COMMUNICATION

A Novel Anatomical Consideration on the

Exposed Segment of the Facial Artery
JI-HYUN LEE,1 KANGWOO LEE,1 WONSUG JUNG,2 KWAN-HYUN YOUN,3
KYUNG-SEOK HU ,1 TANVAA TANSATIT,4 HYUN JUN PARK,5* AND HEE-JIN KIM 1,6*

1
Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification
Research Center, BK21 PLUS Project, Yonsei University College of Dentistry, Seoul, South Korea
2
Department of Anatomy, Yonsei University Medical College, Seoul, South Korea
3
Division in Biomedical Art, Incheon Catholic University Graduate School, Incheon, South Korea
4
Chula Soft Cadaver Surgical Training Center and Department of Anatomy, Faculty of Medicine,
Chulalongkorn University, Bangkok, Thailand
5
Maylin Clinic, Seoul, South Korea
6
Department of Materials Science & Engineering, College of Engineering, Yonsei University Seoul, South
Korea

An understanding of the location and depth of the facial artery (FA) is essential
in aesthetic surgery and various cosmetic procedures. The purpose of this study
was to clarify the three-dimensional (3D) topography of the exposed segment
(ES) of the FA and to provide information to help minimize complications during
clinical procedures. From 50 embalmed adult cadavers, the undissected and dis-
sected hemifaces were scanned and reconstructed using the 3D scanner. Then
the topographic location of the ES was identified and measured from the sup-
erimposed the 3D images. The ES was observed in 82% of the whole speci-
mens. The exposure patterns of the ES were examined, and classified into three
types: Type I, one site exposed pattern (74%); Type II, two sites exposed pat-
tern (8%); and Type III, nonexposed pattern (18%). The extent of the ES was
located at 2.2 mm above and 4.2 mm below the cheilion (Ch)—otobasion
inferius line, and 20.0 to 25.2 mm from the Ch on the lateral aspect. In the fron-
tal view, the average distance from the mid-pupillary line to the ES was
7.1 mm, and from the lateral canthal line to the ES was 6.1 mm. The ES was
7.6 mm below the skin surface. The results of this study will help to provide safe
guidelines for filler injections as well as selecting the safe regions in various clin-
ical procedures. Clin. Anat. 00:000–000, 2019. © 2019 Wiley Periodicals, Inc.

*Correspondence to: Hyun Jun Park, Maylin Clinic, 21 Apgujeong-ro 29-gil, Gangnam-gu, Seoul 06005, South Korea.
E-mail: parmani@naver.com AND Hee-Jin Kim, Room 601, Department of Oral Biology, Yonsei University College of Dentistry, 50 Yonsei-ro,
Seodaemun-gu, Seoul 03722, South Korea. E-mail: hjk776@yuhs.ac
Abbreviations used: Ch, cheilion; ES, exposed segment; FA, facial artery; LCL, lateral canthal line; NLF, nasolabial fold; Oi, otobasion
inferius; OOr, orbicularis oris; ZMj, zygomaticus major.
Presented at: 8th Asia Pacific International Congress of Anatomists (APICA) 2018 in Busan, South Korea.
Author contributions: H.-J.K. and H.J.P.: overall organization and direction of the research (supervision), providing an anatomical
and clinical opinion (conception), and final revision and drafting of the manuscript. J.-H.L.: overall planning the research, data acqui-
sition, analysis and interpretation and major drafting and revision of the manuscript submission. K.-W.L.: data acquisition, analysis
and interpretation, photographic works, and providing an anatomical opinion (conception). W.J.: planning the research with
anatomical viewpoints (conception), data acquisition, and revision of the manuscript. K.-H.Y.: planning the research with anatomical
viewpoints (conception), data acquisition and revision of the manuscript, drawing the pictures. K.-S.H.: data acquisition, providing
anatomical opinion reference (conception). T.T.: data acquisition, interpretation, and photographic works of harvesting data.
Received 16 August 2019; Revised 17 September 2019; Accepted 17 September 2019
Published online 00 Month 2019 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/ca.23495

© 2019 Wiley Periodicals, Inc.

2 Lee et al.

Key words: facial artery; nasolabial fold augmentation; 3D scanning system;

surface landmark

INTRODUCTION location and depth of the exposed segment (ES) of the

The nasolabial fold (NLF) is defined as the facial
wrinkle that extends from each side of the nose to the
corresponding corner of mouth (Rubin et al., 1989;
Standring, 2008). The NLF appears as an aging phe-
nomenon, and is treated using various minimally inva-
sive procedures such as NLF augmentation (Wollina,
2016; Scheuer 3rd et al., 2017; Faris et al., 2018;
Mowlds and Lambros, 2018). Improper manipulation
during volume enhancement using dermal filler injec-
tion procedures can produce various complications,
including vascular accidents of the facial artery
(FA) (Bailey et al., 2011; Kassir et al., 2011; Park
et al., 2011; Daley et al., 2012; Ozturk et al., 2013).
While the distribution of the FA has been described in
various ways in many publications, a common descrip-
tion is that the FA terminates at the nasal tip or angular
region after passing the ala of the nose (Koh et al.,
2003; Pinar et al., 2005; Loukas et al., 2006; Yang
et al., 2014; Lee et al., 2015; Pilsl et al., 2016). This
indicates that most of the FA are primarily supplying
the perioral region bounded by the nasal base, the NLF,
and the labiomental crease (Ponsky and Guyuron,
2011). As it courses to the ala of nose, the FA trunk is
exposed to the subcutaneous layer in the area bordered
by the orbicularis oris (OOr), risorius, and zygomaticus
major (ZMj) muscles (Lee et al., 2018). This means
that the FA is not protected by any muscles in this area,
thereby increasing the probability of vessel damage
during clinical procedures. An understanding of the
FA in the facial subcutaneous layer is therefore impor-
tant to reduce the probability of vessel damage.
This study aimed at clarifying the three-dimensional
(3D) topography of the ES of the FA and providing
information to help minimize the complications during
the clinical procedures by identifying the location of
the ES based on the surface landmarks that are easily
recognizable on the face.
MATERIALS AND METHODS
Cadaveric Dissection and 3D Scanning
Using a Structured-Light Scanner
Fifty hemifaces from 50 embalmed Korean and Thai
cadavers (31 males and 19 females with a mean age of
76.6 years) were used in this study. There were no
cadavers with the history of surgery, trauma, pathologi-
cal results, or congenital malformation. The location and
depth of the ES were measured by scanning each speci-
men using a structured-light 3D scanner (Morpheus3D®,
Morpheus Company, Seongnam, Korea). The intact
facial skin surface of each cadaver was scanned using a
structured-light scanner, and then the skin of the face
and subcutaneous tissue were gently dissected, after
which the specimen was scanned again using the 3D
scanner. The acquired 3D scanned images were
reconstructed, and the images of each layer were sup-
erimposed using the Morpheus Dental Solution (MDS)
software (version 3.0, Morpheus Company) (Fig. 1).

Fig. 1. Superimposition of reconstructed images of each layer using the Morpheus

Dental Solution (MDS) software. (a) Scanned image of the layer of the facial skin sur-
face. (b) Scanned image of the facial muscular layer. (c) Superimposed image of the
images of (a) and (b) using the software. The green area indicates the
dissected area. [Color figure can be viewed at wileyonlinelibrary.com]
 Exposed Segment of Facial Artery 3

Fig. 2. Measurements of the location of the exposed segment (ES) of the facial
artery, and the distance from surface landmarks on the face to the ES using the Mor-
pheus Dental Solution (MDS) software. The position of the boundary of the ES was mea-
sured at six points (black dots). To maximize the area of the ES, the exposed points of
the ES from the muscle layer, the entry points to the muscle layer, and the points of the
medial and lateral borders of the ES were measured. The x-axis is the line from the
cheilion (Ch) to the otobasion inferius (Oi) (Ch-Oi line), and the y-axis is the line perpen-
dicular to the x-axis at the Ch. [Color figure can be viewed at wileyonlinelibrary.com]

Classification of the Exposure Patterns of
the ES and Relationships to the Facial
Muscles
Based on the reconstructed images of the dissected
specimens by MDS software, the exposure patterns of
the ES were examined, and classified into three types
according to the number of exposures: (1) in Type I
the ES was exposed at one site, (2) in Type II the ES
was exposed at two sites, and (3) in Type III the ES
was not exposed. Type I cases were subdivided
according to the exposed extent of the vessel: Type Ia
was where up to 1 cm of the ES was exposed, and
Type Ib was where the linear exposure exceeded 1 cm.
The positional relationships between the ES and the
surrounding muscle structures were also investigated.
Topographic Analyses of the ES
The location, length, and area of the ES were mea-
sured using topographic analysis of the 3D images of
the muscle layer. Both the depth of the ES from the
skin and the distance from the facial landmarks to the
ES were measured in a frontal view by comparing
each layer, and the measurements were analyzed
using the MDS software (version 3.0). The detailed
measurements were as follows:
1. The locations of the border of the ES above the mus-
cle layer were measured on the line from the cheilion
(Ch) to the otobasion inferius (Oi) (henceforth
referred to as the Ch-Oi line) (Fig. 2).
2. The area of the border of the ES and the length of
the ES on the muscle layer.
3. The depth of the ES below the skin surface. In the
case of a nonexposed FA was located deeper than
the modiolus, the depth of the FA below the skin
was measured.
4. The distances from the surface landmarks on the
face to the line perpendicular to the points over-
lapping the medial and lateral borders of the ES
(Lm and Ll, respectively) were measured on the
skin surface along the Ch-Oi line. The distances
from the mid-pupillary line (MPL) to Lm and Ll, the
distances from the lateral canthal line (LCL) to Lm
and Ll, and the distance from the Ch to Lm were
also measured (Fig. 3).
Statistical calculations and analyses were per-
formed using Microsoft Excel software (Office
365, Microsoft, Redmond, WA).
RESULTS
Exposure Patterns of the ES of the FA and
Relationships to the Facial Muscles
The ES was observed in 82% of the whole speci-
mens. Type I was observed in 74% of the specimens
(Fig. 4a), with 62% and 12% being Types Ia and Ib,
4 Lee et al.
Fig. 3. Measurements of the location of the exposed
segment (ES) of the facial artery. The distances from the
surface landmarks to the vertical line to the skin point
overlapping the ES were measured on the skin surface
along the cheilion (Ch) to the otobasion inferius (Oi) (Ch-
Oi line). a, Distance from the mid-pupillary line (MPL) to
Lm; b, distance from the MPL to Ll; c, distance from the
lateral canthal line (LCL) to Lm; d, distance from the LCL
to Ll; and e, distance from the Ch to Lm. Lm, the line per-
pendicular to the point overlapping the medial border of
the ES; Ll, the line perpendicular to the point overlapping
the lateral border of the ES. [Color figure can be viewed
at wileyonlinelibrary.com]
respectively. Type II was observed in 8% of the speci-
mens (Fig. 4b), and both exposed sites were shorter
than 1 cm. Type III that without the ES was observed
in 18% of the specimens (Fig. 4c). The topographic
relationships between the ES and the surrounding
muscle structures were classified into three patterns
(Fig. 5). The ES was located between the ZMj and
risorius in 62.2% of cases, between two muscle bun-
dles of the bifid ZMj in 28.9%, and between the ris-
orius and the depressor anguli oris in 8.9%.
Topographic Measurements of the ES of
the FA
The ES was located 2.2  6.7 mm (mean  SD)
above the Ch-Oi line and 4.2  6.7 mm below the Ch-Oi
line, and between 20.0  5.2 mm and 25.2  5.3 mm
from the Ch on the lateral aspect of the face (Fig. 6). In
most cases, the ES of the FA was within 5 mm above or
below the Ch-Oi line (82.2% of the ES-present Type I
and II cases). The ES crossed the Ch-Oi line in 62.2%
of cases, and was located above and below the Ch-Oi
line in 24.4% and 13.3%, respectively.
In a frontal view of the reconstructed image, the
average distances from the MPL to the location of
the ES (Lm and Ll) were 7.1  4.4 mm and 11.1 
5.0 mm, respectively; the corresponding distances
from the LCL were 6.1  5.6 mm and 10.0  5.4 mm,
respectively. The average distance from the Ch to Lm
was 14.0  3.9 mm (Fig. 7). The ES was exposed on
the lateral side of the LCL in a frontal view in two cases.
The area and length of the ES were 18.7  10.9 mm2
and 6.5  4.0 mm, respectively. The ES was
7.6  2.7 mm below the skin surface. In the ES-absent
Type III cases, the FA was 13.2  1.4 mm below the
skin surface on the lateral aspect of the corner of the
mouth.
DISCUSSION
The increasing demand for face-lift procedures,
soft-tissue augmentations, and minimally invasive pro-
cedures such as dermal fillers and threads is increasing
the incidence of various side effects (Ozturk et al.,
2013; Carruthers et al., 2014; Thanasarnaksorn et al.,
2018). Ozturk et al. identified three severe types of
complications—soft-tissue necrosis, visual impairment,
and anaphylaxis—in a review of the complications of
soft-tissue filler injections. The main injection sites
associated with soft-tissue necrosis and visual impair-
ment were identified as the nose (33% and 34%,
respectively), the glabella (26% and 21%), and the
NLF (26% and 31%). These complications of soft-
tissue augmentation may be caused by damage to the
blood vessels due to direct injury by the needle, intra-
vascular embolisms by injection materials, or com-
pression by the injected filler materials (Ozturk et al.,
2013). In order to minimize the complications that
may occur during filler injections to high-risk areas
such as the nose, glabella, and NLF, the physician
should use a blunt cannula and apply a moderate pres-
sure to slowly inject the appropriate amount of filler.
Other precautions should also be taken, including aspi-
ration before injection (Lazzeri et al., 2012; Ozturk
et al., 2013; Carruthers et al., 2014). However,
Feinendegen et al. reported a case of global aphasia
and mild sensorimotor hemiparesis on the right
side caused by infarction of the left middle cerebral
artery following filler injections into the NLF using a
 Exposed Segment of Facial Artery 5

Fig. 4. Exposed patterns of the exposed segment (ES) of the facial artery. The
exposure of the ES on the muscle layer was classified into three types and subdivided
according to length. (a) Type Ia, where the ES is exposed at one site for up to 1 cm.
(b) Type Ib, where the ES is exposed at one site for longer than 1 cm. (c) Type II,
where the ES is exposed at two sites. (d) Type III, where the ES is not exposed. Black
arrowheads indicate the ES. [Color figure can be viewed at wileyonlinelibrary.com]

Fig. 5. Topographic relationships of the exposed segment (ES) of the facial artery
with the surrounding muscles. (a) Pattern in which the ES is located between the
zygomaticus major (ZMj) and the risorius (Rs). (b) Pattern in which the ES is located
between two muscle bundles of the bifid ZMj. (c) Pattern in which the ES is located
between the Rs and the depressor anguli oris (DAO). Black arrowheads indicate
the ES. [Color figure can be viewed at wileyonlinelibrary.com]
6 Lee et al.

The nasolabial area around the corner of mouth

Fig. 6. Measurements of the location of the exposed
segment (ES) of the facial artery. The x-axis is the
cheilion (Ch) to otobasion inferius (Oi) line, and the y-
axis is the line perpendicular to the x-axis at the Ch.
[Color figure can be viewed at wileyonlinelibrary.com]
and the ala of nose is characterized by an abundance
of blood vessels. Yang et al. reported that the bra-
nches of the FA passed near the NLF in 93% of cases
and that the FA was located within 5 mm from the NLF
in 43% of cases (Yang et al., 2014). This indicates
that physicians need to take special care when per-
forming dermal filler procedures involving the NLF.
The general anatomy textbook describes the FA as
running deeper than the skin and cheek fat and deeper
than both the ZMj and risorius around the corner of
mouth (Standring, 2008). However, Lee et al. described
that the FA was exposed on the muscle layer between
the OOr, ZMj, and risorius at the lateral side of the cor-
ner of mouth in 85% of cases (Lee et al., 2018). This
means that the FA in the nasolabial area is particularly
vulnerable to damage because it is not protected by
muscle. This area is occasionally used as an entry point
for NLF treatment, and so knowledge of the topography
of the FA in this area can help prevent vascular damage
during NLF treatments (Chen and Khan 2009; Chen

2-mm-diameter cannula (Feinendegen et al., 1998).

That case report indicates that using a blunt cannula
does not always prevent vascular damage. To minimize
any side effects, it is necessary to use caution during
the operation and to possess detailed knowledge about
the location and depth of the blood vessels in the
treated area.
For numerous diagnoses and surgical or nonopera-
tive evaluations, 3D scanned images of the face are
now popularly used (Hammond et al., 2004; Kim et al.,
2018). The validity and reliability of measurements
using the 3D scanning system were demonstrated in
our previous study (Lee et al., 2017; Cong et al., 2019;
Kim et al., 2019). This 3D scanning system acquires
distance information based on structured light, which
can be measured with an accuracy of better than
0.1 mm. Therefore, it was thought that this precise 3D
imaging scanning procedure could yield crucial in-depth
anatomical information to provide reliable data in vari-
ous minimally invasive clinical procedures.
The FA is an important vessel that supplies blood to
the skin and muscles of the face, and can be damaged
even during minimally invasive procedures. The pos-
sibly fatal consequences of such damage have
prompted active morphological studies of the FA. The
FA has been variously classified by researchers into
three to six patterns based on its last arterial branch.
Koh et al. categorized the FA into six patterns, Pinar
et al. and Loukas et al. categorized it into five pat- Fig. 7. Average distance from surface landmarks to
terns, Pilsi et al. categorized it into four patterns, and the points overlapping the exposed segment (ES) of the
Lee et al. categorized it into three patterns. The facial artery on the skin in a frontal view. In a frontal
results of these studies commonly show that in most view, the ES was located at mean distances of 7 mm and
cases the FA ascends at least to the ala (88–94% of 11 mm from the mid-pupillary line (MPL) on the lateral
cases), suggesting that it is mainly distributed around side, and of 6 mm and 10 mm from the lateral canthal
the mouth and nose (Koh et al., 2003; Pinar et al., line (LCL) on the medial side. The mean distance from
2005; Loukas et al., 2006; Lee et al., 2015; Pilsl the cheilion (Ch) to the ES in a frontal view was 15 mm.
et al., 2016). [Color figure can be viewed at wileyonlinelibrary.com]
 Exposed Segment of Facial Artery 7

Fig. 8. Predicted danger zone of the exposed segment (ES) of the facial artery.
The ES is likely to be located within 5 mm from the cheilion (Ch) to the otobasion
inferius (Oi) line, between the mid-pupillary line (MPL) and lateral canthal line (LCL)
in a frontal view. The blue area indicates the danger zone. [Color figure can be viewed
at wileyonlinelibrary.com]

and Khan, 2010; Scheuer 3rd et al., 2017; Rubin and
Neligan, 2018).
In the present study, we named the area where the
FA is not covered by muscles as the ES and attempted
to obtain information about its topographic relation-
ships. Similar to Lee et al., the ES was observed at
the lateral area of the corner of mouth in 82% of
cases(Lee et al., 2018). The ES was mostly exposed
at one site only, but it was exposed at two sites in 8%
of the analyzed specimens. In addition, the ES was
mainly located between the OOr, risorius, and ZMj in
the lateral area of the corner of mouth; but in the
presence of the bifid ZMj, the ES had a high probabil-
ity of being exposed between the OOr and the two
muscle bundles of the bifid ZMj. We observed the bifid
ZMj in 40% of cases, which is consistent with the find-
ings of previous studies (Hu et al., 2008).
In 79.5% of the cases (70% of all the specimens
observed) the ES located within 5 mm above or below
the Ch-Oi line, while simultaneously being located
between the MPL and LCL in a frontal view. The ES
(Type I and II cases) located shallower than the FA
located on the lateral aspect of the corner of mouth in
the ES-absent Type III. Hence, the danger zone—
where the ES is likely to be located—can be estimated
as being within 5 mm from the Ch-Oi line and
between the MPL and the LCL in a frontal view
(Fig. 8). In most cases, this site is unprotected by
muscles, which makes it more vulnerable, and so it is
not recommended to use this area as an entry point
for filler injection and other noninvasive procedures.
Moreover, when making the entry point for the
cannula, a physician should penetrate the skin with
the needle only very shallowly in this region.
Our results will help to provide safe clinical guide-
lines for NLF augmentation. Knowledge of the location
of the danger zone that we have determined can be
useful not only during filler injections but also for
selecting safe areas in various other treatments such
as botulinum neurotoxin injections, face lifting, pro-
duction of skin flaps, and thread lifting. A blunt can-
nula should be used when injecting into this region,
and it should be inserted slowly while considering the
location and depth of the ES of the FA. Conclusively,
injections to the danger zone should be avoided; and
when treating this site, injections into the subcutane-
ous layer should be reconsidered.
ACKNOWLEDGMENTS
The authors are grateful to the cadaver donors and
their families who participated in the donation pro-
gram. The authors thank Hwi-Eun Hur (BA) from
Davidson College for her revision of this manuscript.
This work was supported by the National Research
Foundation of Korea (NRF) grant funded by the Korean
government (MSIP) (NRF-2017R1A2B4003781).
CONFLICT OF INTEREST
All authors were well-informed of the WMA Decla-
ration of Helsinki—Ethical Principles for Medical
Research Involving Human Subjects—and confirmed
that the present study firmly fulfilled the declaration.
8 Lee et al.
None of the authors have financial or private relation-
ships with commercial, academic, or political organi-
zations or people that could have improperly
influenced this research. All cadaveric objects in this
study were legally donated to Yonsei Medical Center
and Chulalongkorn University. None of the authors
has any proprietary/financial interest. No conflicting
relationship exists for any author.
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