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Surgical Danger Zones of the Head & Neck

Howard Steinman, M.D.Irving, TX

Disclaimers

No Conflicts of Interest

Anatomic Facial Danger Zones

Vessels - Fillers Muscles- Botulinum Nerves - Surgery

Filler Danger Zones

Vascular occlusion / compression

Glabella suptratrochlear artery Lip labial artery NLF angular artery

Vascular Occlusion / Compression

Can occur with any type of filler Supratrochlear

Angular

Labial

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Glabella

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

8/30/07 9/05/07

9/07/07 10/03/07 12/03/07 6/05/09

Glaich AS: Dermatol Surg 2006;32:276–281

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Inject above or below muscle!

muscle

Cohen J: J Drugs Dermatol 2009;8:13

14 hours after injection of HA filler in the glabella

Cohen J: Dermatol Surg 2008;34:S92–S99

Nasolabial Fold – Angular Artery

Dermatol Surg 2007;33:357–360

Angular a. Lateral Nasal a.

Cohen J: J Drugs Dermatol 2009;8:13

Blood Supply

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Dermatol Surg 2007;33:357–360

X

Dermatol Surg 2007;33:357–360

Vascular occlusion of the terminal branch of the angular artery (white

arrow).

37 y/o woman, 4 days s/p injection of HA gel

Dermatol Surg 2011;37:375–380 Dermatol Surg 2011;37:375–380

Dermatol Surg 2007;33:357–360

Labial Artery Labial Artery

Cohen J: J Drugs Dermatol 2009;8:13

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Occlusion Treatment Protocol

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

inject hyaluronidase

Glaich, Cohen & Goldberg, Dermatol Surg 2006;32:276–281

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;32:276–281

Botulinum Danger Zones

Botulinum Danger Zones

Lateral orbital rim Zygoma Oral commissure Chin Neck

Danger Zone Considerations

Dosage Volume Diffusion

Dermatol Surg 2007;33:S37–S43

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O

O

O

Crow’s 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

Orbital Rim

BoTnA: Crow’s Feet

O

O

O

BoTnA: Crow’s Feet

Lateral rectus muscle

BoTnA: Crow’s Feet Diplopia Ectropion Epicanthal fold

distortionXXX

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O

O

O

Zygoma

Do not go too low into zygoma (<0.5 – 1.0 cm)

Avoid affecting lip elevator muscles

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Botulimum Danger Zones

Central & Lateral Chin

Inject Depressor Anguli Oristo Raise Oral Commissure

Superior portion largely aponeurotic

Much of the DAO Overlies Depressor Labii

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Depressor Anguli Oris

Superior portion largely aponeurotic

X

Depressor Anguli Oris

Inject just lateral to a line drawn through the NLF to jawline

Oral and Maxillofacial Surgery Clinics of North America 2009;21:13-21

Mentalis

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

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BTX Injection of Platysma

Pre BTX injection

© 2002 A. Blitzer, MD

2 weeks post BTX injection

Pre BTX injection

© 2002, PPS®. All Rights Reserved.

Platysma Muscle

Extremely Thin

Danger Zone Considerations

Placement Dosage Volume Diffusion

Botox: Platysmal BandsComplications

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 SurgeryBrooke R. Seckel

Quality Medical Publishing, Inc.

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Nerves

XI

Temporal Branch of VII

Temporal Branch of VII

Located beneath superficial temporal fascia

Temporal Branch of VII

SMAS

Nerve

Temporal Branch of VII1. Line from 0.5 cm below 

tragus to 2.0 cm above lateral eyebrow.  Draw second line on zygoma to lateral orbital rim.  Connect two lines

2. Draw line from tragus to lateral canthus.  Draw second line from tragus to highest forehead crease (some say frontal hairline)

Temporal Branch of VII

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Marginal Mandibular N. VII

Beneath SMASVery superficial Paresis of lip depressors

Marginal Mandibular N. VII

Marginal Mandibular N. VIIDraw line 2.0 cm lateral to oral commissure

Drop line from this point to mid‐mandible

Draw circle 2 cm around this point

Marginal Mandibular N. VIIENT Training:

Two cm below entire mandubular rim 

ENT Danger Zone

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Spinal Accessory Nerve (XI)

NOT covered by platysma (SMAS)

XI Nerve

Posterior Neck Triangle

Courtesy of David Butler, M.D.

SAN Damage

Symptoms Shoulder pain (the most common

presenting symptom) can radiate to the neck, upper back &

ipsilateral arm.

SAN Damage

Signs Diminished strength when raising arm

overhead putting weight on shoulder Muscle atrophy Winged Scapula

Winged Scapula

Dermatol Surg 2000;26:384–386

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Erb’s Point

SAN at greatest risk traverses posterior border of

sternocleidomastoid muscle into posterior triangle of neck

Erb’s Point

Erb’s Point Erb’s Point

Draw line from angle of jaw to mastoid

From midpoint of this line –

Drop line from this midpoint to posterior border of SCM

Erb’s Point Know The Danger Zones

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Thank You