Cosmetic Medicine

Aesthetic Surgery Journal

2021, Vol 41(6) 697–704
Three-Dimensional Description of the © The Author(s) 2020. Published
by Oxford University Press on behalf
Angular Artery in the Nasolabial Fold of The Aesthetic Society. All rights re-
served. For permissions, please e-mail:
[email protected]
DOI: 10.1093/asj/sjaa152
www.aestheticsurgeryjournal.com

Pavel Gelezhe, MD; Victor Gombolevskiy, MD, PhD;

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Sergey Morozov, MD, PhD; Dmitry V. Melnikov, MD, PhD;
Tatiana Aleksandrovna Korb, MD; Olga Olegovna Aleshina, MD;
Konstantin Frank, MD; Robert H. Gotkin, MD; Jeremy B. Green, MD; and
Sebastian Cotofana, MD, PhD

Abstract
Background: Due to its arterial vasculature, the nasolabial sulcus is one of the most challenging facial regions to treat
when trying to ameliorate the signs of facial aging.
Objectives: The aim of the present study was to provide data on the 3-dimensional course of the angular artery within the
nasolabial sulcus in relation to age, gender, and body mass index to increase safety during minimally invasive treatments.
Methods: Thee hundred nasolabial sulci from 75 males and 75 females of Russian Caucasian ethnic background (mean
[standard deviation] age, 45.7 [18.7] years; mean body mass index, 25.14 [4.9] kg/m2) were analyzed. Bilateral multiplanar
measurements were based on contrast-enhanced computed tomography cranial scans.
Results: Up to 3 arteries could be identified within the nasolabial sulcus: ~90% contained 1 arterial trunk, ~9% had 2
trunks, and ~1% had 3 trunks; females had more arteries than men. The artery is located at mean depths of 21.6 mm at the
oral commissure and 8.9 mm at the nasal ala. The angular artery was lateral to the nasolabial sulcus in 100% of cases; the
smallest distance between the artery and the nasolabial sulcus was at the oral commissure (11.91 [7.9] mm) and the greatest
was at the nasal ala (13.73 [3.9] mm).
Conclusions: In contrast to current concepts, the angular artery is not located strictly subdermal to the nasolabial sulcus
but at a variable depth, and in 100% of the investigated cases lateral to the nasolabial sulcus. With increasing age, the
depth and lateral distance between arteries and sulci reduces significantly, underscoring the need for special caution
when injecting this site.

Editorial Decision date: May 28, 2020; online publish-ahead-of-print June 6, 2020.

Drs Gelezhe, Gombolevskiy, Morozov, Korb, and Aleshina are

physicians, Research and Practical Clinical Center for Diagnostics Department of Clinical Anatomy, Mayo Clinic College of Medicine
and Telemedicine Technologies of the Moscow Health Care and Science, Rochester, MN, USA.
Department, Moscow, Russia. Dr Melnikov is a physician, Plastic
Surgery Department, I.M. Sechenov First Moscow State Medical Corresponding Author:
University, Moscow, Russia. Dr Frank is a physician, Department for Dr Sebastian Cotofana, Department of Clinical Anatomy, Mayo Clinic
Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians University, College of Medicine and Science, Mayo Clinic, Stabile Building 9-38,
Munich, Germany. Dr Gotkin is a physician in private practice in New 200 First Street, Rochester, MN 55905, USA.
York, NY, USA. Dr Green is a physician in private practice in Coral E-mail: [email protected];
Gables, FL, USA. Dr Cotofana is a physician and associate professor, Instagram: @professorsebastiancotofana
698 Aesthetic Surgery Journal 41(6)

The nasolabial sulcus is one of the most challenging fa- Russia (protocol no 5), and the patients gave their informed
cial regions to treat when trying to ameliorate the signs consent for the use of their personal and CT imaging data.
of facial aging. The challenges in treating this area arise CT measurements relied the segment of the facial ar-
from the underlying anatomy. The sulcus is an area of tery running beneath the nasolabial sulcus being fully vis-
adhesion where the muscles of facial expression have a ible. The segment of the facial artery located within the
strong connection to the overlying dermis.1,2 This zone of nasolabial sulcus is termed the “facial artery” before the
adhesion causes a change in the subcutaneous architec- branching of the superior labial artery and the “angular ar-
ture although no clear delineation between fat, muscle fi- tery” after the bifurcation of the superior labial artery.9 Due
bers, connective tissue, and skin is evident.3 This change to variations in the superior labial artery branching pattern,
in subcutaneous arrangement is physiologic and explains various names for the main arterial trunk have been used.
why even babies and adolescents present with nasolabial However, for the sake of uniformity, the main arterial trunk
sulci of varying depths. With increasing age, the appear- identified near or beneath the nasolabial sulcus will be

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ance of the sulcus changes as the cranially located soft termed the “angular artery” in the following discussion.
tissues descend,4 pseudoherniate over the sulcus, and
create the illusion of a deeper furrow that may be con-
sidered undesirable.
Image Analyses
There are multiple approaches to improving the appear- CT scans were acquired with a Toshiba Aquilion LB scanner
ance of the nasolabial sulci with soft tissue volumizers such as (Toshiba Medical Systems Corporation, Ōtawara, Tochigi,
fat5 or hyaluronic acid–based fillers.6-8 A recent anatomic re- Japan) with the following scanning parameters: voltage
view suggested treating the nasolabial sulcus via intradermal 120 kV, slice thickness 0.47 mm, field of view 220 mm, and
or supraperiosteal product placement to avoid contact with tube current 140 mA.
the angular artery located below the skin.9 Choosing tissue In each CT scan, the nasolabial sulcus was identified
planes where the facial arterial vasculature is not located is on the skin surface by adjusting the soft tissue visibility
thought to increase safety during minimally invasive filler in- through Hounsfield unit regulation. The total length of the
jections. Avoiding the pathways and planes of the facial ar- sulcus was defined as the visible depression extending
teries is of the utmost importance, as it has been shown that between the inferolateral margin of the nasal ala and the
intra-arterial product placement can cause tissue loss and lateral aspect of the oral commissure. The total length of
injection-related visual compromise (IRVC) of varying de- the nasolabial sulcus was then subdivided into 3 equidis-
grees, including cases of irreversible blindness.10-12 tant segments (S1, S2, S3) which were bounded by their
The angular artery has been reported to course within respective margins (P1, P2, P3, P4) (Figure 1).
the depth of the nasolabial sulcus; 13 however, there is a All measurements were performed bilaterally with the in-
dearth of information regarding accurate measures of ternal software tools of Intellispace 8.0 (Philips, Koninklijke,
depth and lateral distances, and how these dimensions Amsterdam, the Netherlands). The following parameters
may potentially vary with age, gender, and body mass were assessed:
index (BMI). Therefore, the objective of the present study
• total length (mm) of the nasolabial sulcus;
was to provide data on the 3-dimensional course of the an-
• extent (mm) of each of the 3 segments, ie, distance
gular artery within the nasolabial sulcus in relation to age,
between P1 and P2 = S1; distance between P2 and
gender, and BMI. It is hoped that providing a clearer under-
P3 = S2; distance between P3 and P4 = S3 (Figure 1);
standing of the arterial pathway in this high-risk area may
• number of arteries observed in each segment;
lead to safer aesthetic injections.
• depth of the main arterial trunk (mm) at each meas-
ured location, ie, P1, P2, P3, P4 (depth measurements
METHODS were performed perpendicular to the maximal depth
of the nasolabial sulcus even if the artery was located
Study Sample lateral to the sulcus, as shown previously9)(Figure 2);
• lateral distance between the main arterial trunk and a
Computed tomography (CT) scans from the radiology
vertical line passing through the maximal depth of the
database of the Research and Practical Center of Medical
nasolabial sulcus, as shown previously9 (Figure 2).
Radiology of the Department of Health Care, Moscow,
Russia, were retrospectively analyzed for the purposes of
the present study. The image analysis procedures were car-
Statistical Analyses
ried out between January and July 2019, and utilized scans
previously obtained during routine contrast-enhanced CT Multiplanar measurements (Figures 3 and 4) were re-
cranial examinations. The study was approved by the peated 3 times and validated by 2 independent observers
Ethics Committee of the Department of Health, Moscow, for reporting consistency. The relation between the length
Gelezhe et al 699

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Figure 3. Three-dimensional rendering of a contrast-
enhanced computed tomography cranial image of a 63-year-
old male patient. Segments (S1-S3) and measurement points
(P1-P4) have been visualized.

of the nasolabial sulcus and patient age, gender, and BMI

was calculated from bivariate correlations and general-
Figure 1. Schematic drawing superimposed on a clinical ized linear models with robust estimators. The depth of
image of a 22-year-old female showing the measurements the artery and the distance between the artery and the
performed: the location of P1 at the inferolateral margin nasolabial sulcus were calculated from independent t tests
of the nasal ala and of P4 at the lateral aspect of the oral (side and gender differences), bivariate correlations, and
commissure. The distance between P1 and P4 (the length of
generalized linear models with robust estimator. Results
nasolabial sulcus) was divided into 3 equal segments (S1, S2,
S3). The number of arterial branches observed within each were considered statistically significant if the difference
segment S1 to S3 is given within each segment (each artery was P ≤ 0.05. All tests were run with SPSS Statistics 23
is represented by a red line). Numbers are not stratified by (IBM, Armonk, NY).
gender.

RESULTS
Demographic Data
The investigated sample is a subsample of a previously
described cohort14 and consisted of 75 males and 75 fe-
males of Russian Caucasian ethnic background having a
mean [standard deviation] age of 45.7 [18.7] years (range,
14-89 years) and a mean BMI of 25.14 [4.9] kg/m2 (range,
16.7-47.8 kg/m2). Both facial sides were investigated, re-
sulting in the analysis of 300 nasolabial sulci. No statis-
tically significant differences between facial sides were
detected in any of the measured parameters (all P ≥ 0.333).
Figure 2. Schematic drawing showing the multiplanar
measurements of the depth of the angular artery and Length of Nasolabial Sulcus
the lateral distance between the angular artery and the
nasolabial sulcus. Measurements were performed in The mean length of the nasolabial sulcus was 31.26 [4.0] mm
perpendicular axes. (range, 23.0-43.0 mm) in males and 28.84 [3.9] mm (range,
700 Aesthetic Surgery Journal 41(6)

A B

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C D

Figure 4. Multiplanar (sagittal, axial, coronal) measurements of a 63-year-old male patient. (A) A sagittal view with locators
(blue and orange lines) centered on the angular artery. (B) An axial view with the locators (red and orange lines) centered on
the angular artery. (C) A coronal view with the locators (red and blue lines) centered on the angular artery. (D) A 3-dimensional
reconstruction and the measured segment (S2) of the respective angular artery.

22.0-42.0 mm) in females (P < 0.001 for gender differences). data in S1 showed that 1 arterial trunk was found in 91.0%,
The length of the sulcus was significantly influenced by 2 arterial trunks in 8.3%, and 3 arterial trunks in 0.7% of the
increasing values of BMI (P = 0.009) and by male gender investigated cases. In the S2 segment, 1 arterial trunk was
(P < 0.001) but not by increasing values of age (P = 0.559). found in 90.3%, 2 in 8.7%, and 3 in 1.0% of the cases. In S3,
1 arterial trunk was found in 90.6% and 2 in 9.4% of the in-
vestigated nasolabial sulci (Figure 1).
Number of Arteries
The mean number of arteries per segment was significantly Depth of the Main Arterial Trunk
different between genders; in every segment investigated
(S1-S3), females displayed a greater number of main ar- The main arterial trunk started deep at the oral commis-
terial trunks (S1, P = 0.018; S2, P = 0.040; S3, P = 0.015). sure and became more superficial toward the nasal ala—
Detailed information is presented in Table 1. Unstratified P4: 21.61 [6.9] mm (range, 3.0-43.6 mm); P3: 20.69 [6.2]
Gelezhe et al 701

Table 1. Number of Arterial Trunks Observed Beneath the Table 2. Depth of the Main Arterial Trunk Beneath the
Nasolabial Sulcus Stratified by Gender Nasolabial Sulcus Stratified by Gender

S1* S2* S3* P1* P2* P3* P4*

Male 1.05 [0.3] 1.07 [0.3 1.05 [0.2] Male 7.35 [2.4] 12.66 [3.8] 16.9 [3.4] 17.67 [3.5]

Female 1.14 [0.4] 1.15 [0.4] 1.14 [0.3] Female 10.52 [4.6] 19.10 [5.9] 24.79 [6.0] 26.38 [7.2]

Statistically significant differences between gender with P < 0.05 are marked Statistically significant with P < 0.001 are marked with an asterisk.
with an asterisk.

mm (range, 9.0-40.4 mm); P2: 15.84 [5.88] mm (range, 6.0- No statistically significant correlation was found between
33.5 mm); P1: 8.93 [4.0] mm (range, 1.0-26.0 mm). In each depth and lateral distance measures; this indicates that the

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measured location, females had a significantly deeper ar- artery did not course in a cluster-like pathway (deep and
terial course than males (P < 0.001) (Table 2). lateral or superficial and closer to the nasolabial sulcus)
Analyzing the frequency of the angular artery within with P ≥ 0.098.
the superficial/middle/deep tertile of the depth of the Increasing values of age, but not BMI, reduced statisti-
nasolabial sulcus revealed a homogeneous distribution cally significantly the distance between the angular artery
across tertiles (Table 3). This indicates a high variability in and nasolabial sulcus independent of gender when ap-
the depth of the artery across the investigated sample with plying generalized linear models.
men having a more superficial course than females.
A highly statistically significant positive correlation was
found between the arterial depths at each consecutive DISCUSSION
measured location, indicating that, despite the great varia-
bility in depth (see above), the main arterial trunk followed The present study analyzed previously obtained cranial CT
a constant pathway within its initial depth. From P4 to P3: scans to determine the course of the angular artery in 300
rP = 0.868, P < 0.001; P3 to P2: rP = 0.758, P < 0.001; P2 to nasolabial sulci. The results revealed that up to 3 arteries
P1: rP = 0.729, P < 0.001. could be identified independent of their location between
Applying generalized linear models with adjustment for the oral commissure and the nasal ala: ~90% had 1 arterial
age and BMI revealed that the depth of the main arterial trunk, ~9% had 2 trunks, and ~1% had 3 trunks, with females
trunk was not influenced by increasing BMI values at P2, having more arteries per measured segment than males.
P3, and P4. However, with increasing age there was a sta- One strength of the study is the large number of in-
tistically significant decrease in distance between the skin vestigated nasolabial sulci (n = 300); to the best of our
surface and the main arterial trunk in those locations. knowledge, this is the largest sample in which the arterial
vasculature beneath the sulcus has been evaluated with
Position of the Main Arterial Trunk high-resolution CT scans. Another strength of the study
(Lateralization) is the stringent measurement technique, which utilized
multiplanar distance measurements to achieve superior
In all of the measured cases, the artery was found to course accuracy. Of note, the CT scans were obtained with pa-
lateral to the nasolabial sulcus. The mean distance be- tients in the supine position as is routine for cranial CT
tween the artery and the nasolabial sulcus was as follows: scanning procedures. This could have resulted in lateral
at P1, 13.73 [3.9] mm (range, 3.8-25.0 mm); at P2, 12.87 [6.0] and/or cranial soft tissue shifting. The conducted meas-
mm (range, 1.0-33.0 mm); at P3, 12.81 [8.2] mm (range, 1.5- urements, however, relied on the relation of the arterial
40.0 mm); and at P4, 11.91 [7.9] mm (range, 1.0-36.0 mm). vasculature to the nasolabial sulcus and not on bony or
The distance from the arterial trunk to the sulcus was at on other nonmobile/fixed landmarks. It is unlikely that the
all measured locations statistically significantly greater in subdermal soft tissues move to a greater or lesser extent
males than in females (Table 4). than the overlying skin, indicating that if there is any lateral
Similar to those findings related to depth, a highly sta- or cranial shift of the facial soft tissue the arterial vascula-
tistically significant positive correlation was found in the ture moves concomitantly.
distance between the artery and the sulcus at each con- A limitation of the study is that it is a retrospective
secutive measured location, indicating that, despite the analysis of a cohort exclusively comprised of Russian
high variability in distance values (see above), the main Caucasian individuals. It is unclear whether these results
arterial trunk followed a constant pathway within its ini- are extrapolatable to other races/ethnicities. However,
tial position. From P4 to P3: rP = 0.866, P < 0.001; P3 to the present study is the largest CT-based analysis of
P2: rP = 0.823, P < 0.001; P2 to P1: rP = 0.618, P < 0.001. the angular artery within the nasolabial sulcus, and the
702 Aesthetic Surgery Journal 41(6)

Table 3. Distribution of the Frequency of the Angular Artery Beneath the Superficial/Middle/Deep Tertile of the Nasolabial Sulcus
P1* P2* P3* P4*

Range, Male Female Range, Male Female Range, Male Female Range, Male Female
mm count (%) count (%) mm count (%) count (%) mm count (%) count (%) mm count (%) count (%)

Superficial <7.0 85 (56.7) 35 (23.3) <12.0 80 (53.3) 21 (14.0) <17.0 89 (59.3) 18 (12.0) <18.0 87 (58.0) 18 (12.0)
tertile

Middle tertile 7.1-9.9 38 (25.3) 35 (23.3) 12.1-17.9 48 (32.0) 46 (30.7) 17.1-21.9 49 (32.7) 39 (26.0) 18.1-22.9 53 (35.3) 52 (34.7)

Deep tertile >10.0 27 (18.0) 80 (53.3) >18.0 22 (14.7) 83 (55.3) >22.0 12 (8.0) 93 (62.0) >23.0 10 (6.7) 80 (53.3)

Statistically significant differences at each measured location are indicated by asterisks.

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Table 4. Lateral Distance of the Main Arterial Trunk to the the aforementioned assumption of the relative increase
Nasolabial Sulcus Stratified by Gender of facial soft tissues cranial to the sulcus due to an in-
crease in BMI. This increase in BMI could facilitate the
P1* P2* P3* P4
descent of the heavier soft tissues,16 resulting in an ac-
Male 15.16 [3.9] 14.58 [6.8] 14.75 [9.6] 12.62 [9.1] cumulation of volume cranial to the nasolabial sulcus.
Female 12.27 [3.5] 11.10 [4.4] 10.68 [5.7] 11.03 [5.8]
This was shown in our study by the increase in length of
the nasolabial sulcus under the influence of BMI but not
Statistically significant results with P < 0.001 are marked with an asterisk. under the influence of age. Some common clinical mor-
phologic observations are that people with heavy, round
faces do not display deep nasolabial sulci. It is often the
measurement techniques employed could be used as
people with normal to low BMIs—thin people—who dis-
guidance for future investigations. Studying other ethnici-
play a deep nasolabial sulcus. It is important to note that
ties with the methodology described herein would widen
this is a single-point-in-time, cross-sectional study and
the applicability of this approach and reduce the bias be-
not a longitudinal study. It would certainly add valuable
tween published results. Another limitation of the study is
information to the literature to follow the same subjects in
that due to the study set-up, the angular artery was inves-
a longitudinal manner and take the same measurements
tigated at rest only, and did not take account of soft tissue
as they age.
movements during facial expressions. These soft tissue
Minimally invasive aesthetic procedures targeting im-
movements might influence arterial position and course,
provement of the nasolabial sulcus frequently rely on di-
which might lead to different results to those presented
here. Future studies will need to investigate the magnitude rect nasolabial augmentation via the injection of fat or other
of these positional changes to ultimately predict angular types of soft tissue volumizers. These procedures could
arterial course more precisely. potentially result in IRVC10,11 due to intra-arterial injection
The present study is confirmatory in many aspects of the product. The current belief that the facial/angular ar-
and provides a deeper understanding of the facial aging tery is located in the immediate proximity of the dermis of
process. The presence of a nasolabial sulcus can be ob- the nasolabial sulcus should be reconsidered. Our results
served in babies, adolescents, young adults, and the eld- reveal that the artery is located at mean depth of 21.6 mm
erly. This is the result of the underlying anatomy; many at the oral commissure and at a mean depth of 8.9 mm at
of the muscles of facial expression attach and form a the nasal ala (overall mean, 16.6 mm) with shallower depths
strong connection to the dermis at the nasolabial sulcus.3 for males than for females (Table 3). These results indicate
This attachment between muscle and dermis—along the that, on average, the artery is not located in the immediate
nasolabial sulcus—forms the inferior boundary of the su- subdermal location; this could provide a valid explanation
perficial (subdermal) nasolabial fat compartment.4,15 With for why many nasolabial volume augmentation procedures
increasing age, the nasolabial sulcus appears deeper and do not result in an IRVC. Nevertheless, these results need
more prominent, but not necessarily longer. This seems to be interpreted with great caution: the range of arterial
to be the result of a relative increase in volume of the depth is from 1.0 to 43.6 mm; this shows that the artery
facial soft tissues secondary to an age-related facial soft can indeed be found immediately beneath the dermis.
tissue descent, especially of the cranially located super- Therefore, one should always practice preinjection aspira-
ficial fat compartments of the medial cheek. In our study, tion, a slow injection of small boluses, and choose a plane
individuals with a higher BMI—but not older age—dis- where the arteries are less frequently identified for product
played a longer nasolabial sulcus. This would confirm deposition, ie, the supraperiosteal plane.
Gelezhe et al 703

However, the artery seemed to be constant both in its (P4-P1) reveal that once the artery courses in close prox-
depth and in its course relative to the nasolabial sulcus. imity to the nasolabial sulcus it remains, with a statisti-
Utilizing bivariate correlations showed that the depth in cally significant high probability, close to the sulcus and
one location along the nasolabial sulcus is significantly vice versa.
correlated to the depth at the next location. This could pro- Injectable filler treatments should be customized based
vide mathematical evidence for a constant rather than a on a patient’s age. Utilizing generalized models revealed
torturous course of the angular artery within/adjacent to that with increasing age there was a statistically signifi-
the nasolabial sulcus. The depth of the angular artery was cantly reduced distance between the nasolabial sulcus
reduced in elderly individuals; this is plausible as the fa- and the evaluated main arterial trunk. This finding is con-
cial aging process includes fatty tissue atrophy and volume sistent with the current understanding of the anatomy of
loss,4,17 and a loss in the thickness of the fatty layers re- the aging face, as with increasing age fat tissue mass is
duces the distance between skin surface and main arte- lost and the filling material surrounding the arteries is re-

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rial trunk. Interestingly, individuals with higher BMI did not duced. This results in less protection for the facial vascu-
display a greater depth of the main arterial trunk. This can lature, and as shown in this study in a reduced distance to
be attributed to the attachment of the muscles of facial ex- the nasolabial sulcus. These results would imply that older
pression to the overlying dermis at the nasolabial sulcus. individuals are at a potential greater risk for IRVCs during
This zone of adhesion seems to prevent any increase injectable treatments of the nasolabial sulcus, as the artery
in the thickness of the subcutaneous fat at this location. is more superficial and located closer to the sulcus than
Consequently, there is no statistically significant relation in younger individuals. This emphasizes again the need
between higher BMI and the depth of the main arterial to re-evaluate the subdermal injection technique, which
trunk within the sulcus. based on the results of this study should be replaced by
Another reason to reconsider the assumption that the supraperiosteal injection technique. Applying new
the angular artery is located immediately beneath the concepts for facial soft tissue filler injections, such as the
nasolabial sulcus are the lateral distance measurements lateral-first or the upper-face-first approach,18 where the
between the nasolabial sulcus and the main arterial trunk: temple, the zygomatic arch, and/or the malar prominence
in all of the samples investigated, the position of the main are targeted first, might reduce the necessity to inject the
arterial trunk was lateral to the nasolabial sulcus. The nasolabial sulcus directly. These injections are shown to
smallest distance was at the oral commissure (11.91 [7.9] have an effect on the midfacial soft tissues, which can re-
mm) and the greatest distance to the sulcus was at the position the age-related descent and reduce the aestheti-
nasal ala 13.73 [3.9] mm. In all of the measured locations, cally unpleasing appearance of the nasolabial sulcus.
females demonstrated a smaller distance between the
nasolabial sulcus and the main arterial trunk. This would be
CONCLUSIONS
in line with a previous publication which reported a stable
location of the facial artery:9 crossing the mandibular The results of the present study reveal that within the depth
margin anterior to the masseter muscle and at the mod- of the nasolabial sulcus up to 3 arterial trunks can be iden-
ulus. The latter agrees with the results presented herein, tified. In contrast to current concepts, the angular artery
where the smallest distance between the sulcus and the is not located strictly subdermally in the nasolabial sulcus
main arterial trunk was observed at P4—the level of the but at a variable depth that is greater at the oral commis-
oral commissure. sure than at the nasal ala. Additionally, the artery is located
Clinically, this is relevant because the typical dermal ac- lateral to the nasolabial sulcus at a variable distance, with
cess point to inject the nasolabial sulcus is at the caudal a greater distance at the nasal ala. With increasing age,
end of the sulcus. Here, special care should be taken as the depth of the angular artery and the lateral distance be-
the artery could be in close proximity. Anecdotally, clinical tween the nasolabial sulcus and the artery reduce signifi-
aesthetic injectable education has emphasized the need cantly, underscoring the need for vigilance when injecting
for caution when injecting the nasolabial sulcus near the soft tissue fillers at this site in older patients. The facial fatty
nasal ala, but training has not similarly focused on the po- volume loss reduces the tissue surrounding the arteries,
tential dangers when injecting its caudal end. The range exposing them and making them more prone to puncture
of the distance measurements is 1.0 to 36.0 mm, providing during injectable treatments.
evidence for the tortuous and variable course of the artery
when comparing different individuals (rather than following Acknowledgments
the main arterial trunk within the same nasolabial sulcus). The authors would like to thank Zamyatina Ksenia, Alekseeva
However, the high correlation coefficients as a result of the Tatyana, Chernyshev Dmitry Olegovich, Titov Mikhail, and
bivariate correlations between each consecutive location Suleimanova Maria for their support during data analysis.
704 Aesthetic Surgery Journal 41(6)

Disclosures 9. Cotofana S, Lachman N. Arteries of the face and their

relevance for minimally invasive facial procedures: an
The authors declared no potential conflicts of interest with
anatomical review. Plast Reconstr Surg. 2019;143(2):
respect to the research, authorship, and publication of this
416-426.
article.
10. Beleznay K, Carruthers JDA, Humphrey S, Jones D.
Avoiding and treating blindness from fillers. Dermatologic
Funding Surg. 2015;41(10):1097-1117.
The authors received no financial support for the research, 11. Beleznay K, Carruthers JDA, Humphrey S, Carruthers A,
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