2/12/2013

Disclaimers
No Conflicts of Interest

Surgical Danger Zones of the

Head & Neck
Howard Steinman, M.D.
Irving, TX

Anatomic Facial
Danger Zones
Vessels - Fillers
Muscles- Botulinum
Nerves - Surgery

Filler Danger Zones

Vascular occlusion / compression
Glabella
Lip
NLF

suptratrochlear artery
labial artery
angular artery

Vascular Occlusion / Compression

Can occur with any type of filler

Supratrochlear

Angular

Labial

2/12/2013

Glabella

Occlusion or compression of
supratrochlear a.
watershed region
minimal collateral circulation

9/07/07

10/03/07

8/30/07

9/05/07

12/03/07

6/05/09

Glaich AS: Dermatol Surg 2006;32:276281

2/12/2013

Inject above or
below muscle!

muscle

Nasolabial Fold Angular Artery

14 hours after injection of

HA filler in the glabella
Cohen J: J Drugs Dermatol 2009;8:13

Cohen J: Dermatol Surg 2008;34:S92S99

Dermatol Surg 2007;33:357360

Angular a.

Lateral Nasal a.

Blood Supply

Cohen J: J Drugs Dermatol 2009;8:13

2/12/2013

Dermatol Surg 2007;33:357360

37 y/o woman, 4 days s/p

injection of HA gel

Dermatol Surg 2007;33:357360

Vascular occlusion of the terminal

branch of the angular artery (white
arrow).

Dermatol Surg 2011;37:375380

Labial Artery

Dermatol Surg 2007;33:357360

Dermatol Surg 2011;37:375380

Labial Artery

Cohen J: J Drugs Dermatol 2009;8:13

2/12/2013

Occlusion Treatment Protocol

Massage / tap area
Hot/warm water compresses
If used hyaluronic acid filler
inject hyaluronidase

Occlusion Treatment Protocol

Nitroglycerine paste under occlusion
-12 h on and 12 h off
Low molecular weight heparin SC
-up to 14 days
Diligent wound care and
observation

Glaich, Cohen & Goldberg, Dermatol Surg 2006;32:276281

Glaich, Cohen & Goldberg, Dermatol Surg 2006;32:276281

Botulinum Danger Zones

Lateral orbital rim
Zygoma
Oral commissure
Chin
Neck

Botulinum Danger Zones

Danger Zone Considerations

Dosage
Volume
Diffusion

Dermatol Surg 2007;33:S37S43

2/12/2013

Crows Feet

Stay 1 cm lateral to orbital

rim following curve or rim
10 15 units per side
Inject 2.5 to 5 U per site

O
O
Orbital Rim

BoTnA: Crows Feet

BoTnA: Crows Feet

O
O
O

BoTnA: Crows Feet

X
X
X

Diplopia
Ectropion
Epicanthal fold
distortion

Lateral rectus muscle

2/12/2013

Zygoma

O
O

Do not go too low into

zygoma (<0.5 1.0 cm)

Avoid
affecting
lip elevator
muscles

2/12/2013

Botulimum Danger Zones

Central & Lateral Chin

Inject Depressor Anguli Oris

to Raise Oral Commissure

Much of the DAO

Overlies Depressor Labii

Superior portion largely aponeurotic

2/12/2013

Depressor Anguli Oris

Depressor Anguli Oris

X
Superior portion largely aponeurotic

Inject just lateral to a line drawn through

the NLF to jawline

Mentalis

Oral and Maxillofacial Surgery Clinics of North

America 2009;21:13-21

Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Boston, MA: Blackwell Science; 2001.
2002, PPS. All Rights
Reserved.

Consensus Recommendations:
Treating Dimpled Chin

Injection sites and dosage of botulinum toxin type A for dimpled chin.
Plast Reconstr Surg 2004:114(6 suppl):1S-22S

2/12/2013

BTX Injection of Platysma

Platysma Muscle
Pre BTX injection
Pre BTX injection

2 weeks post BTX injection

Extremely Thin
2002 A. Blitzer, MD

2002, PPS. All Rights Reserved.

Botox: Platysmal Bands

Complications

Danger Zone Considerations

Placement
Dosage
Volume
Diffusion

Dysphagia: muscles of deglutition

Neck weakness: floppy neck
syndrome
Dry mouth: salivary glands
Voice change

Nerves
Motor
Temporal branch facial nerve
Marginal mandibular nerve
Accessory nerve

Facial Danger Zones; Avoiding Nerve Injury in Facial Plastic Surgery

Brooke R. Seckel
Quality Medical Publishing, Inc.

10

2/12/2013

Nerves

Temporal Branch of VII

XI

Temporal Branch of VII

Temporal Branch of VII

Located beneath superficial

temporal fascia

SMAS

Nerve

Temporal Branch of VII

Temporal Branch of VII

1. Linefrom0.5cmbelow
tragusto2.0cmabove
lateraleyebrow.Draw
secondlineonzygoma to
lateralorbitalrim.
Connecttwolines
2. Drawlinefromtragusto
lateralcanthus.Draw
secondlinefromtragusto
highestforeheadcrease
(somesayfrontalhairline)

11

2/12/2013

Marginal Mandibular N. VII

Beneath SMAS

Very

Marginal Mandibular N. VII

superficial

Paresis of lip depressors

Marginal Mandibular N. VII

Drawline2.0cmlateral
tooralcommissure
Droplinefromthispoint
tomidmandible
Drawcircle2cmaround
thispoint

Marginal Mandibular N. VII

ENT Danger Zone

ENTTraining:
Twocmbelowentire
mandubularrim

12

2/12/2013

Spinal Accessory Nerve (XI)

Posterior Neck Triangle

NOT covered
by platysma
(SMAS)

XI Nerve

SAN Damage
Symptoms
Shoulder pain (the most common
presenting symptom)

can radiate to the neck, upper back &

ipsilateral arm.

Courtesy of David Butler, M.D.

SAN Damage

Winged Scapula

Signs
Diminished strength when raising arm
overhead putting weight on shoulder
Muscle atrophy
Winged Scapula

DermatolSurg2000;26:384386

13

2/12/2013

Erbs Point

Erbs Point

SAN at greatest risk

traverses posterior border of
sternocleidomastoid muscle
into posterior triangle of neck

Erbs Point

Erbs Point

Erbs Point

Draw line from

angle of jaw to
mastoid
From midpoint of
this line
Drop line from this
midpoint to
posterior border of
SCM

Know The Danger Zones

14

2/12/2013

Thank You

15