Received: 27 September 2021 Revised: 28 November 2021 Accepted: 28 November 2021

DOI: 10.1002/ca.23817

REVIEW

Termination points of the facial artery—A meta-analysis

Mateusz Koziej | Michał Bonczar | Patryk Ostrowski |

Katarzyna Piątek-Koziej | Tomasz Bonczar | Artur Pasternak |
Martyna Dziedzic | Jerzy Walocha

Department of Anatomy, Jagiellonian

w, Poland
University Medical College, Krako
Correspondence
Mateusz Koziej, Department of Anatomy,
Jagiellonian University Medical College,
Mikołaja Kopernika 12, 33-332 Krako
w,
Poland.
Email: mateusz.koziej@gmail.com
Abstract
The facial artery (FA) is the main artery supplying the anterior face, making this artery
a very important structure to consider while performing plastic and reconstructive
procedures. The literature shows discrepancies in anatomical classifications and the
frequency of occurrence of individual variations. Therefore, the goal of this meta-
analysis is to provide surgeons with helpful knowledge about the variety of the termi-
nation of FA. Articles with data about the termination of the FA were found in major
online medical databases such as PubMed, Scopus, Embase, Web Of Science, and
Cochrane Library. A total of 1346 articles were initially evaluated by two indepen-
dent reviewers. Out of those, 24 articles matched the required criteria, and were
used in this meta-analysis. A total of 2119 studied FAs were included in this study.
The FA termination patterns were divided into five previously classified types. The
data show that the FA terminates most frequently as the lateral nasal or angular
artery with the prevalence for this group being 69.81% (95% confidence interval [CI]:
59.83%–78.94%). Authors believe that this is the most accurate and up to date study
regarding termination patterns and the prevalence of the FA. The results of this
meta-analysis could provide a helpful tool for surgeons preforming plastic and cos-
metic procedures, especially when injecting dermal fillers or choosing and preforming
facial flaps. Detailed anatomical knowledge about the FA may prevent potential sur-
gical complications.

KEYWORDS
angular artery, blood supply, face, facial artery, lateral nasal artery

1 | I N T RO DU CT I O N
The facial artery (FA) is a branch of the external carotid artery and
supplies facial muscles and skin. Anatomical textbooks describe the
FA as arising just above the upper border of the hyoid bone, coursing
deep to the mandible, winding up around the inferior border of the
mandible, and then running upward and forward on the face (Chung &
Chung, 2011). The FA has both cervical and facial branches, such as
the ascending palatine artery and the inferior and superior labial arter-
ies (Drake et al., 2015). During the fourth and fifth weeks of embryo-
logical development, the aortic arches develop from the aortic sac.
The third aortic arch gives then rise to the external carotid artery,
from which the FA develops (Hanneman et al., 2017).
The terminating branch of the FA is variable in the literature
(Lohn et al., 2011; Loukas et al., 2006; Pilsl et al., 2016). Some of these
terminating branches that have been recorded include the FA termi-
nating as the superior labial, lateral nasal, angular arteries, and others
(Koh et al., 2003). Early termination of the FA has also been recorded,
and these reports include the submental, inferior labial, and alar arter-
ies (Cardinot et al., 2014; Vadgaonkar et al., 2012). Therefore, the FA,
and its branches, can potentially be found in any location from the
neck to the midface area.

Clinical Anatomy. 2022;35:469–476. wileyonlinelibrary.com/journal/ca © 2021 American Association of Clinical Anatomists. 469

470
Understanding the variability of both the course and termination
of the FA is of great clinical importance in plastic surgery. Plastic and
aesthetic procedures, such as dermal injections, are increasing in pop-
ularity with the midface being one of the most common facial injec-
tion sites. Understanding the vasculature of the midface can therefore
decrease potential complications that arise with dermal injections.
These complications can include visual impairment or skin necrosis
(Ozturk et al., 2013). Plastic and reconstructive surgeons should also
take the results from this meta-analysis into consideration when
designing a facial artery musculomucosal flap (FAMM), which has
emerged as a popular option in head and neck reconstruction during
the last decade (Ayad & Xie, 2015).
The goal of this meta-analysis is to provide surgeons with helpful
knowledge about the variety of the termination of FA, and with that
knowledge, produce a decrease in the possible dangers associated
with the FA in several reconstructive and plastic surgical procedures.
2 | MATERIALS AND METHODS
2.1 | Search strategy
Significant articles about the termination of the FA were found on
major online medical databases such as PubMed, Scopus, Embase,
Web Of Science, and Cochrane Library. For PubMed, Cochrane and
Embase the following terms was used:
((facial artery) OR (FA) OR (arteria facialis) OR (external maxillary
artery) OR (arteria maxillaris externa)) AND ((anatomy) OR (variations)
OR (variant) OR (anomalies) OR (branching) OR (course) OR (division)
OR (pattern) OR (aberrant)) AND ((termination) OR (end) OR (comple-
tion) OR (finale) OR (finish)).
However, for the databases Scopus and Web Of Science the fol-
lowing scheme was used: (facial artery) OR (arteria facialis) OR (exter-
nal maxillary artery) OR (arteria maxillaris externa) OR (angular artery)
OR (arteria angularis). Date, language, article type, and/or text avail-
ability conditions were not applied. Reference searches of the
included studies were conducted to ensure the thoroughness of the
process. During this study, the Preferred Reporting Items for System-
atic Reviews and Meta-Analyses (PRISMA) guidelines were followed.
2.2 | Eligibility assessment
A total of 1346 articles were initially evaluated by two independent
reviewers. Out of those, 89 qualified for a full-text evaluation. The
inclusion criteria were set as follows: original studies with extractable
numerical data regarding the topic of this study, whereas the exclu-
sion criteria involved conference reports, case reports, case series,
reviews, letters to the editor, patients with a noticeable pathology
that could potentially distort the FA anatomy, studies with no relevant
or incompatible data. Eventually, 24 articles matched the required
criteria, and were used in this meta-analysis.
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KOZIEJ ET AL.
2.3 | Data extraction
Data from qualified studies were extracted by two independent
reviewers. Numerical data about the different types of termination of
FA was extracted from the studies and used in this meta-analysis. Any
discrepancies between studies as identified by the two reviewers
were resolved using an article by Hwang et al. (2015), by contacting
the authors of the original studies wherever possible or by consensus
with a third reviewer.
2.4 | Statistical analysis
In this meta-analysis, STATISTICA version 13.1 software (StatSoft
Inc., Tulsa, OK, USA) and MetaXL version 5.3 (EpiGear International
Pty Ltd, Wilston, Queensland, Australia) were used to calculate the
resulting prevalence of FA. A random-effects model was created. The
heterogeneity among the studies was evaluated using both the chi-
square test and I-squared statistic (Higgins et al., 2019). The I-squared
statistic was interpreted based on a specific scale: (1) 0%–40% as
“might not be important”, (2) 30%–60% as “may represent moderate
heterogeneity, (3) 50%–90% as “may represent substantial heteroge-
neity”, and (4) 75%–100% as “may represent considerable heteroge-
neity”. A p value <0.05 and confidence intervals (95% CI) were used
to probe for statistically significant differences between the study
groups. If the confidence intervals between the groups overlapped,
the differences were considered as insignificant, while in the reverse
situation, the differences were considered statistically significant.
3 | RE SU LT S
3.1 | Study evaluation
After searching the databases and performing a manual search through
the references, a total of 1346 studies were initially assessed. Among
those, 89 were admitted for a more comprehensive evaluation. Fifty-
three studies were excluded due to their irrelevant subject material and
incomplete or absence of data. Twelve more studies were rejected
because they were either case reports or conference abstracts. Eventu-
ally, 24 studies that matched the required criteria and contained both
complete and relevant data were included in this meta-analysis. The
overall process of collecting data is shown in Figure 1. Characteristics
of each study that fulfilled all criteria for inclusion are shown in Table 1.
Out of 24 studies, 20 were based on cadaver dissections regarding a
total of 1274 arteries in 745 cadavers (Dickson et al., 2014; Dupoirieux
et al., 1999; Gardetto et al., 2002; Gocmen-Mas et al., 2015; Koh et al.,
2003; Laurentjoye et al., 2012; Lee, Gil, et al., 2015; Lee, Yang, et al.,
2015; Lohn et al., 2011; Loukas et al., 2006; Midy et al., 1986; Mitz
et al., 1973; Nakajima et al., 2002; Niemann et al., 2019; Niranjan,
1988; Pilsl et al., 2016; Pinar et al., 2005; Qassemyar et al., 2012; Saban
et al., 2012; Tansatit et al., 2021), three on computed tomography
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KOZIEJ ET AL. 471

angiography (CTA) images of a total of 726 arteries gathered from

423 patients (Furukawa et al., 2013; Hong et al., 2020; Koziej et al.,
2019) and one included 119 arterial patterns gathered from 110 human

zwa, 1977). In total, morphological data of 2119
fetuses (Kozielec & Jo
arteries were included in this meta-analysis.

3.2 | Data extraction

Qualified studies differed both in terminology and in approach of

grouping and outputting the gathered data. As a solution, the authors
decided to assemble the extracted termination patterns of FA in an
apportionment that included all data. For this purpose, the compila-
tion method presented by Furukawa et al. (2013) with later modifica-
tion by Koziej et al. (2019) as shown in Figure 2 was used. In this
compilation method, the FA termination patterns were divided into
five types: (1) Type 1 is a short FA course, in which it terminates prox-
imally to the superior labial artery as the superior or inferior labial
artery; (2) In type 2, the FA terminates distally to the superior labial
artery near the nasolabial fold as an inferior alar artery; (3) In type
F I G U R E 1 Flow diagram presenting process of collecting data
3, the FA extends to the lateral nasal or angular branch and runs in
included in this meta-analysis
the alar-facial crease; (4) In type 4, the FA forms a duplex with the

T A B L E 1 Characteristics of each
First author Publication date Continent Country
study included in this meta-analysis
Tansatit T. 2021 Asia Thailand
Hong S. J. 2020 Asia South Korea
Koziej M. 2019 Europe Poland
Niemann K. 2019 Africa South Africa
Pilsl U. 2016 Europe Austria
Lee S. H. 2015 Asia South Korea
Lee J. 2015 Asia South Korea
Gocmen-Mas N. 2015 Asia Turkey
Dickson G. 2013 Europe United Kingdom
Furukawa M. 2013 North America USA
Laurentjoye M. 2012 Europe France
Saban Y. 2012 Europe France
Qassemyar Q. 2012 Europe France
Lohn J. W. G. 2011 Europe United Kingdom
Loukas M. 2006 North America USA
Pinar Y. A. 2005 Asia Turkey
Koh K. S. 2003 Asia South Korea
Gardetto A. 2002 Europe Austria
Nakajima H. 2002 Asia Japan
Dupoirieux L. 1999 Europe France
Niranjan N. S. 1988 Europe United Kingdom
Midy D. 1986 Europe France
Kozielec T. 1977 Europe Poland
Mitz V. 1973 Europe France

472
dominant lateral angular branch and traverses the supra-alar crease,
which is its anatomical landmark; and (5) In type 5, FA is hypoplastic
and the remaining course is supplied by the dominant transverse facial
artery (Furukawa et al., 2013; Koziej et al., 2019). All types and distri-
bution of results from each study are presented in Table 2.
3.3 | Meta-analysis
The prevalence of each termination type was determined regarding all
24 included studies.
Termination type 1 included FA termination on the superior or
inferior labial artery. The prevalence of type 1 was found to be 15.55%
(95% CI: 10.93%–20.79%). It may be suggested that data regarding
type 1 may represent considerable heterogeneity as the I2 was 88.91.
Termination type 2 included FA termination on inferior alar
artery. The prevalence of type 2 was found to be 5.89% (95% CI:
1.51%–12.49%). It may be suggested that data regarding type 2 may
represent considerable heterogeneity as the I2 was 96.12.
Termination type 3 included FA termination on the lateral nasal
or angular artery. The prevalence of type 3 was found to be 69.81%
(95% CI: 59.83%–78.94%). It may be suggested that data regarding
type 3 may represent considerable heterogeneity as the I2 was 95.45.
Termination type 4 included FA termination as a dominant lateral
branch. The prevalence of type 4 was found to be 1.72% (95% CI:
0.61%–3.31%). It may be suggested that data regarding type 4 may
represent considerable heterogeneity as the I2 was 78.97.
Termination type 5 included a hypoplastic FA. The prevalence of
type 5 was found to be 0.81% (95% CI: 0.37%–1.41%). It may be
suggested that data regarding type 5 may represent moderate hetero-
geneity as the I2 was 32.58. All results mentioned above are pres-
ented in Table 3.
Despite the statistics regarding all studies, analysis of data based
on a study type was also performed. Among submitted articles, three
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KOZIEJ ET AL.
F I G U R E 2 Diagram presenting
termination patterns of the facial
artery (FA) according to the
compilation method presented by
Furukawa et al. (2013) with later
modification by Koziej et al. (2019).
(A) Type 1—FA terminating as a
superior or inferior labial artery;
(B) Type 2—FA terminating as an
interior alar artery; (C) Type 3—FA
terminating as a lateral nasal or angular
artery; (D) Type 4—FA terminating as a
dominant lateral branch; (E) Type 5—
hypoplastic FA
were based on CTA, and 21 were cadaveric studies. As the prevalence
of each termination type in both groups was calculated, Type 3 was
established to be the most common pattern in both groups. The dif-
ferences in each type of prevalence between the CTA-based and
cadaveric studies were found to be insignificant. All established p-
values were < 0.05, so it may be suggested that no statistically signifi-
cant differences between those two study methods existed. These
results are shown in Table 4.
Additional statistics were performed for FA termination as a lat-
eral nasal or angular artery after dividing type 3 into two subtypes.
For this purpose, only the data from studies that clearly separated lat-
eral nasal and angular artery in their results were used (Dickson et al.,
2014; Dupoirieux et al., 1999; Gocmen-Mas et al., 2015; Hong et al.,
2020; Koh et al., 2003; Laurentjoye et al., 2012; Lee, Yang, et al.,
2015; Lohn et al., 2011; Loukas et al., 2006; Midy et al., 1986;
Niemann et al., 2019; Niranjan, 1988; Pilsl et al., 2016; Pinar et al.,
2005; Qassemyar et al., 2012; Tansatit et al., 2021), hence data
regarding 1339 arterial patterns were included in these statistics.
The prevalence of FA termination as a lateral nasal artery was
found to be 43.83% (95% CI: 31.56%–56.47%). It may be suggested
that data regarding FA termination as a lateral nasal artery may repre-
sent considerable heterogeneity as the I2 was 94.85. The prevalence
of FA termination as an angular artery was found to be 30.40% (95%
CI: 19.19%–42.89%). It may be suggested that data regarding FA ter-
mination as an angular artery may represent considerable heterogene-
ity as the I2 was 95.10. A p-value between those two subtypes was
0.20. Results mentioned above are shown in Table 5.
4 | DI SCU SSION
The FA is considered a relatively sizeable vessel and is one of main
arteries of the facial region; however, studies describing its branching
patterns with termination points are not consistent. The main fields in
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KOZIEJ ET AL. 473

TABLE 2 Summarized data of termination types of the facial artery (FA) presented in all studies included in this meta-analysis

Type 1—
Superior or Type 2— Type 4— Type 5—
First author inferior Inferior Type 3—Lateral Dominant Hypoplastic
of the study Year No. labial alar nasal or angular lateral branch FA
Tanvaa Tansatit 2021 62 (31 cadavers) 3 — 59: 5—Lateral Nasal; 54—Angular — —
Seok Jin Hong 2020 284 (198 CTA cases) 42 — 242: 138—Lateral Nasal; 104—Angular — —
K Niemann 2019 39 (20 cadavers) 6 4 28: 20—Lateral Nasal; 8—Angular — 1
M Koziej 2019 255 (131 CTA cases) 63 80 102 4 6
Ulrike Pilsl 2016 60 (30 cadavers) 11 — 41: 16—Lateral Nasal; 25—Angular 8 —
Jae-Gi Lee 2015 54 (54 cadavers) — — 38: 28—Lateral Nasal; 10—Angular 16 —
Nuket Gocmen-Mas 2015 32 (16 cadavers) 5 4 23: 15—Lateral Nasal; 8—Angular — —
Sang-Hee Lee 2015 60 (36 cadavers) 13 — 47 — —
Matakazu Furukawa 2013 187 (94 CTA cases) 64 74 45 4 —
George Dickson 2013 40 (21 cadavers) 17 3 20: 9—Lateral Nasal; 11—Angular — —
M Laurentjoye 2012 12 (6 cadavers) 2 — 9: 7—Lateral Nasal; 2—Angular — 1
Yves Saban 2012 40 (20 cadavers) — 32 6 — 2
Quentin Qassemyar 2012 20 (10 cadavers) 4 — 16: 11—Lateral Nasal; 5—Angular — —
Jonathan W G Lohn 2011 201 (112 cadavers) 25 35 136: 96—lateral nasal; 40—Angular — 5
M Loukas 2006 284 (142 cadavers) 28 — 256: 245— Lateral Nasal; 11—Angular — —
Y A Pinar 2005 50 (25 cadavers) 2 6 41: 30—Lateral Nasal; 11—Angular — 1
K S Koh 2003 91 (47 cadavers) 11 3 73: 40—Lateral Nasal; 33—Angular 4 —
A Gardetto 2002 44 (31 cadavers) 2 6 34 2 —
Hideo Nakajima 2002 25 (19 cadavers) 1 2 22 — —
L Dupoirieux 1999 20 (10 cadavers) 7 — 13: 9—Lateral Nasal; 4—Angular — —
N S Niranjan 1988 50 (25 cadavers) 2 1 42: 13—Lateral Nasal; 34—Angular 5 —
D Midy 1986 40 (40 cadavers) 16 — 23: 12—Lateral Nasal; 11—Angular — 1
T Kozielec 1977 119 (110 human fetuses) 50 — 69 — —
V Mitz 1973 50 (50 cadavers) 9 — 41 — —

TABLE 3 Statistical result of meta-analysis in each type considering all studies

Termination type Number of arteries Prevalence LCI HCI Q I2 (95% CI)

Type 1—Superior or inferior labial 2119 15.55% 10.93% 20.79% 207.40 88.91 (84.80–91.91)
Type 2—Inferior alar 2119 5.89% 1.51% 12.49% 592.90 96.12 (95.12–96.92)
Type 3—Lateral nasal or angular 2119 69.81% 59.83% 78.94% 506.00 95.45 (94.12–96.43)
Type 4—Dominant lateral branch 2119 1.72% 0.61% 3.31% 109.39 78.97 (69.31–85.60)
Type 5—Hypoplastic FA 2119 0.81% 0.37% 1.41% 34.11 32.58 (0.00–59.02)

Abbreviations: HCI, higher confidence interval; LCI, lower confidence interval; Q, Cochran's Q.

which research studies differ were found to be terminology and prev-
alence of each termination type. Gained prevalence for different ter-
mination vessels oscillated from 15.00% to 95.16% for lateral nasal or
angular artery, from 0.00% to 42.50% for a superior or inferior labial
artery, from 0.00% to 80.00% for an inferior alar, from 0.00% to
29.63% for a dominant lateral branch, and from 0.00% to 8.33% for
an hypoplastic FA (Dickson et al., 2014; Dupoirieux et al., 1999;
Furukawa et al., 2013; Gardetto et al., 2002; Gocmen-Mas et al.,
2015; Hong et al., 2020; Koh et al., 2003; Koziej et al., 2019;

zwa, 1977; Laurentjoye et al., 2012; Lee, Gil, et al.,
Kozielec & Jo
2015; Lee, Yang, et al., 2015; Lohn et al., 2011; Loukas et al., 2006;
Midy et al., 1986; Mitz et al., 1973; Nakajima et al., 2002; Niemann
et al., 2019; Niranjan, 1988; Pilsl et al., 2016; Pinar et al., 2005;
Qassemyar et al., 2012; Saban et al., 2012; Tansatit et al., 2021). The
aim of this meta-analysis was to gather data form previous studies, so
the most accurate prevalence of each termination type could be
determined. This meta-analysis can provide surgeons with up-to-date
knowledge about the termination of the FA.
Over the past few years, the frequency of plastic and aesthetic
procedures has expanded (American Society of Plastic Surgeons,
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474 KOZIEJ ET AL.

TABLE 4 Statistical result of meta-analysis in each termination type, divided regarding a study type

Number of
Termination type Type of study arteries Prevalence LCI HCI Q I2 (95% CI) p value
Type 1—Superior or inferior labial CTA 726 23.67% 13.50% 35.56% 24.53 91.85 (79.30–96.79) 0.16
Cadaveric 1393 14.21% 9.20% 20.08% 156.90 87.25 (81.88–91.04)
Type 2—Inferior alar CTA 726 17.76% 0.00% 57.21% 254.22 99.21 (98.76–99.50) 0.15
Cadaveric 1393 4.71% 1.22% 10.01% 265.59 92.47 (89.82–94.43)
Type 3—Lateral nasal or angular CTA 726 50.72% 10.18% 90.78% 231.10 99.13 (98.61–99.46) 0.66
Cadaveric 1393 72.55% 64.79% 79.69% 183.26 89.09 (84.72–92.21)
Type 4—Dominant lateral branch CTA 726 1.08% 0.00% 2.98% 9.00 77.78 (28.10–93.13) 0.55
Cadaveric 1393 1.83% 0.46% 3.95% 99.79 79.96 (70.11–86.56)
Type 5—Hypoplastic FA CTA 726 0.57% 0.00% 2.23% 10.81 81.50 (42.52–94.04) 0.61
Cadaveric 1393 0.86% 0.39% 1.50% 22.88 12.60 (0.00–47.39)

Abbreviations: HCI, higher confidence interval; LCI, lower confidence interval; Q, Cochran's Q.

TABLE 5 Statistical result of meta-analysis in both subtypes (lateral nasal and angular type)

Termination type Number of arteries Prevalence LCI HCI Q I2 (95% CI)

Lateral Nasal 1339 43.83% 31.56% 56.47% 292.09 94.86 (93.00–96.23)
Angular 1339 30.40% 19.19% 42.89% 306.13 95.10 (93.35–96.39)

Abbreviations: HCI, higher confidence interval; LCI, lower confidence interval; Q, Cochran's Q.

2020; COHEN, 2008). Detailed and accurate anatomical knowledge is
essential for surgeons during cosmetic procedures to prevent poten-
tial complications (Lee et al., 2018). The results of this meta-analysis
should be considered while injecting a facial filler into the midface
area as the prevalence of FA terminating as a lateral nasal or angular
artery was found to be 69.81% (95% CI: 59.83%–78.94%), so the
chance of the FA reaching up to the nose area is immense. Types 2, 4,
and 5 prevalence are relatively small compared to types 3 and 1. Tak-
ing these facts into consideration, it may be assumed that FA mostly
terminates near the nose or lip area, mostly in the medial part of the
mid-face. Surgeons should take this into account while preforming
filler injections as far as the anatomical awareness is paramount to
help avoid vascular and other undesirable sequelae (Surek, 2019).
Plastic and reconstructive surgeons should also consider these results
when performing the facial artery musculo-mucosal flap (FAMM),
which is a versatile reconstruction option for small and medium sized
defects of the oral cavity, oropharynx, lips, nasal septum, and other
less commonly exploited sites (Ayad & Xie, 2015). An intimate knowl-
edge of the vascular anatomy and basic physiology of the skin allows
the reconstructive surgeon to accurately predict and explain the phys-
iological changes that can affect the viability of local skin flaps used to
repair facial defects (Lucas, 2017). It is recommended to preopera-
tively use a Doppler to confirm FA blood flow as this procedure may
result in preventing complications (Céruse et al., 2006). Results from
this meta-analysis should also be a helpful tool for surgeons while pre-
forming the nasal artery musculo-mucosal cutaneous flap (NAMMC),
which is a good alternative for closing wide and recurrent fistulas
(Rossell-Perry & Arrascue, 2012) and also during super-microsurgical
midface reconstruction, because use of the angular artery as the
recipient artery allows shorter flap pedicles and decreases the number
of necessary vein grafts (Yoshimatsu et al., 2019). Blood supply from
FA branches is also used in many other local flaps including nasolabial,
the submental, and the cervicofacial flaps (Wei & Mardini, 2009).
Detailed knowledge of the vascular anatomy and its relationship to
the location of the defect is essential for determining the surgical
technique and choosing a proper flap (Pepper & Baker, 2013). Mohs
surgery is now considered the treatment of choice for many common
and uncommon cutaneous neoplasms (Mansouri et al., 2017). How-
ever, if the tumor is relatively large, and its location is around the area
of the FA, knowledge about the termination points of the FA can be
beneficial when performing this procedure. In recent years, the FA
and facial vein have also been used as one of the pedicles for facial
transplantation. The varying anatomy of the FA confirms the need for
preoperative vascular imaging before facial transplantation surgeries
(Lohn et al., 2011). Understanding the variations in the FA is also
important when constructing an FA perforator flap. Based on multiple
advantages of this procedure, the FA perforator flap is an optimal
choice for defect repair of perioral region and nasal ala (Wang &
Chen, 2017).
The differences in each type of prevalence between the CTA-
based and cadaveric studies were shown to be insignificant. Based on
this finding, it may be assumed that the potential bias of overall
results due to different study designs is close to null. After considering
studies that clearly differentiate lateral nasal artery from angular
artery, the prevalence for both arteries were calculated as the termi-
nation points of the FA. p-Values between those two termination pat-
terns was established as 0.20, and it may be suggested that no
statistically significant differences between those two groups existed

KOZIEJ ET AL.
TABLE 6 Summarized geographic features of admitted articles
Continent Number of studies Number of cases
Europe 13 882
Asia 8 658
North America 2 324
Africa 1 255
Overall 24 2119
although it must be noted that only the studies regarding angular
artery as the final branch of the FA were included in this meta-analy-
sis. The angular artery may also originate from the branching point of
the lateral nasal artery, be continuous from the detouring branch of
the FA, originate from the ophthalmic artery or be undeveloped (Kim
et al., 2014). Hence, it may be assumed that no statistically significant
differences in prevalence between angular and lateral nasal artery as a
termination point of the FA exists, but the prevalence of angular
artery may differ if all origin types were included; thus, the heteroge-
neity between prevalence of angular artery and lateral nasal artery
can be established. This finding should be verified in future studies.
As recently described, the paracentral artery is a vessel that can
originate as a continuation from the angular artery on the forehead or
be a communicating branch of the angular artery with the supra-
trochlear artery (Koziej et al., 2020). It has an important relationship
with the most prominent central vein that is relevant to the construc-
tion of the midline forehead flap (Kleintjes, 2007). In this meta-analy-
sis, the paracentral artery and its prevalence was not included as it
was not considered in submitted articles.
Summarized geographic features of admitted articles can be
found in Table 6. An unequal number of studies from each continent
creates a potential bias. FA termination points were mostly studied in
Europe and Asia, while there are no similar articles involving the South
American and Australian populations. The authors are aware that
results from this meta-analysis may reflect European and Asian people
rather than the global population. Furthermore, due to the limited
amount and inconsistent data regarding lateral dimorphism and the
differences in each gender of the FA terminations patterns, those
aspects were not included in this meta-analysis.
In conclusion, we believe that this is the most accurate and up-to-
date study regarding termination patterns and FA prevalence. FA
mostly terminates as lateral nasal or angular artery as the prevalence
of this group is 69.81% (95% CI: 59.83%–78.94%). It is hoped that
results from this meta-analysis will be a helpful tool for surgeons while
preforming plastic and cosmetic procedures, especially while injecting
dermal fillers or while choosing and preforming facial flaps. Detailed
anatomical knowledge may prevent potential surgical complications.
ORCID
Mateusz Koziej https://orcid.org/0000-0002-2635-0776
Michał Bonczar https://orcid.org/0000-0003-2080-165X
Patryk Ostrowski https://orcid.org/0000-0003-2745-9471
Katarzyna Piątek-Koziej https://orcid.org/0000-0002-4469-6826
Tomasz Bonczar https://orcid.org/0000-0002-4707-7422
10982353, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ca.23817 by Universidad Nacional Autonoma De Mexico, Wiley Online Library on [19/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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How to cite this article: Koziej, M., Bonczar, M., Ostrowski, P.,
Piątek-Koziej, K., Bonczar, T., Pasternak, A., Dziedzic, M., &
Walocha, J. (2022). Termination points of the facial artery—A
meta-analysis. Clinical Anatomy, 35(4), 469–476. https://doi.
org/10.1002/ca.23817