0:03 Which injection is more risky for your
0:05 patients? A vertical injection crossing
0:07 at right angle to the vermillion border
0:09 or a horizontal injection in parallel
0:12 with that structure. This issue divides
0:14 our industry. My audience on Facebook
0:16 and Instagram are also divided down the
0:18 middle about which [music] one is safer.
0:20 So how do we tackle this? I see this
0:22 divided into two factors and really one
0:24 governing principle. Factor one is what
0:26 is the likely anatomy of the label
0:28 artery in the average patient and factor
0:30 two is what is the precise nature of the
0:32 injections we are comparing. We need to
0:33 be very precise with this. The core
0:35 principle here is that the riskiest
0:37 injection is likely to be the one where
0:39 the injecting needle is likely to
0:41 deposit the most amount of product
0:43 nearest the likely position of the
0:45 artery. But I'm not really talking about
0:47 where it could be. I'm trying to think
0:49 about where it's likely to be in every
0:51 in every situation. And you can think
0:53 about the artery a little bit like
0:54 having it's a bit like clouds of
0:56 electrons. I remember learning in
0:58 physics that there's a a a probability
1:00 cloud of where an electron will be in a
1:01 nucleus. It's just like that with
1:03 artery. There's a probability cloud and
1:05 we're trying to think about where the
1:07 probability is and then inject according
1:09 to that. So where is the likely position
1:12 of the superior labial artery? Now the
1:14 artery usually runs above or within the
1:16 vermillion border. The papers that I've
1:18 reviewed have described it routinely in
1:21 the vermillion border or slightly above.
1:23 It's usually also beneath orvicularis
1:26 orus. Sometimes within orvicularosaurus
1:27 and occasionally on top of
1:29 orvicularosaurus. In fact, the ratios
1:31 are about 60% of the time beneath
1:34 orvicularis orusurus about 35% within
1:37 orvicularosaurus and 5% above. And that
1:38 could actually even be in the same
1:39 patient because it probably wiggles
1:41 around a little bit. And of course there
1:43 are anomalous versions of this artery.
1:45 In fact, when I was discussing this with
1:48 Julie Horn recently, she's kindly shared
1:51 an amazing video of a an artery
1:53 pulsating near the wet dry border. Now,
1:54 I've looked into this and actually this
1:57 is a known anomaly. Back in the 70s,
1:59 people had discovered this and it's
2:01 called a caliber persistent artery, but
2:03 it is an anomaly. The normal position of
2:05 the artery, I don't believe, is at the
2:07 wet dry border, but it can be. And this
2:09 is the what we all face as each time we
2:10 inject. There are variations, but we're
2:12 once again talking about the average
2:15 position of the artery. So, look now at
2:18 this cross-section of a lip. This is the
2:19 most important bit of anatomy that you
2:21 will see. This is a hisytoologgical
2:23 specimen cut directly long ways across
2:25 the lip. And you can see where the
2:27 artery tends to lie. We have the muscle
2:29 that runs down the middle of the lip.
2:30 Anterior to that, a little bit of
2:32 hypodermic fats and then the dermis. And
2:34 on the other side, you have underneath
2:36 the m the muscle is where the artery
2:38 usually is. As we've said, it's not
2:39 always at that exact point, but it's
2:41 usually just inferior to or avicularaurus.
2:42 avicularaurus.
2:44 Now, if you picture where your injection
2:46 is, it's on that anterior surface in
2:48 most cases, whether you're horizontal or
2:50 vertical. It's it's in it should be on
2:52 the anterior aspect of the lip. So, now
2:54 we need to think about the technique
2:55 that we're comparing. Now, once again,
2:57 remember, I'm comparing like for like in
2:59 as many different ways as I can keep
3:01 things consistent. Both entry points are
3:03 on the same. That's in the pink part of
3:04 lip. This is very important because I
3:06 think there's a technique which is
3:07 sometimes thrown into the mix which
3:10 confuses the horizontal versus vertical.
3:12 So I'm picturing entering on the pink
3:15 side of the lip in both instances at
3:17 exactly the same point because if you
3:18 change the entry point everything
3:21 changes. Um there is a brutal technique
3:23 where people used to go through the the
3:25 white lip multiple times right through
3:27 where the artery is. And I think this is
3:28 behind why a lot of people really don't
3:30 like vertical injections. But it's
3:32 actually not the way many injectors are
3:34 injecting these days. And I know having
3:35 confirmed this with Julie Horn that her
3:37 technique as most of the ones I've seen
3:39 in recent times are through the pink
3:41 part of the lip which does change things
3:44 completely in my mind. So when I picture
3:46 a vertical injection this is the vision
3:49 in my head. We're entering the pink lip.
3:51 We're skirting superficially. It is a
3:53 superficial injection.
3:55 We're avoiding the deeper part of the
3:57 lip envelope because we're trying to
3:59 rotate the lip up slightly for most of
4:01 those injections. And we're
4:03 progressively moving away from the most
4:05 likely position of the artery. If you
4:07 consider the most likely position is
4:09 just behind orvicularis orus, we would
4:10 start out parallel with it. And the
4:13 needle as it goes deeper in should be
4:15 moving slightly further away. Now
4:17 horizontal injections are the same, but
4:20 we'll be running right over and adjacent
4:22 to the artery. And we would be staying
4:24 in that plane the entire journey of the
4:25 needle. And if you're superficial, you
4:27 should still be away from it, but it's
4:29 technically more likely with an
4:32 anomalous type of anatomy to clip a
4:33 little loop of that artery. Now, with
4:35 this is the issue with normal variation
4:38 in a young client, I cannot see how a
4:40 horizontal injection would be less
4:41 likely to catch the artery than a
4:43 vertical injection because most of the
4:45 time we'd be away from it. So, here's a
4:46 little thought experiment to make it
4:48 even clearer in your mind about what is
4:50 more likely to canulate the artery. If
4:52 instead of avoiding canulating the
4:54 artery, we were to actually purposely
4:56 try and canulate the artery, how would
4:58 you do it? I know how I would do it. I
5:01 would enter parallel with the artery
5:02 because we know the artery runs from
5:04 lateral to medial. It's coming off the
5:06 facial artery across the top of the lip.
5:07 That's the angle my needle would enter.
5:09 And then I would also be deep underneath
5:12 orvicularis orus. And I would poke
5:13 around parallel to the artery until I
5:15 got a flashback. And I I think you'd
5:16 eventually get it if you did it that
5:18 way. I don't think it would make any
5:21 sense to enter vertically because that
5:23 would decrease the chance that you're
5:25 going to get the needle into the into
5:27 the actual lumen. And this is certainly
5:29 how I understand it at the moment. There
5:30 would still be a chance that you could
5:32 do it, but it doesn't make sense to me
5:33 there would be higher than being
5:35 parallel with it. But here's the bit
5:37 that changed for me when I was looking
5:39 into all of this. I was thinking about
5:41 some of the studies that we have,
5:42 Kadaava studies in particular, and
5:44 thinking about how lips change over
5:47 time. So older people tend to have much
5:48 smaller lips. In fact, it's one of the
5:50 reasons why people have their lips done
5:52 is because with age they will involute
5:54 and you can almost lose your lip
5:56 entirely as you get atrophy of the the
5:58 vermillion part of the lip. Now this
6:01 changes everything because if you
6:02 picture trying to do a vertical
6:04 injection on someone with very small
6:07 lips or with atrophied lips, you are
6:09 naturally heading towards the space in
6:11 the retrovicularis orus and that's where
6:14 the artery is. So there are actually
6:15 circumstances where if you apply
6:17 vertical that you're actually going to
6:18 be getting closer to the artery in some
6:21 people. Now I don't think it's the
6:23 obvious injection to do in those cases.
6:24 For me that's not how I would inject
6:26 that type of lip. But remember this
6:28 isn't about how I inject. It's about
6:29 understanding the anatomy in different
6:31 circumstances. So my mental model has
6:33 been improved by thinking about this
6:35 because I've realized that if you treat
6:37 someone with very small lips, you are
6:40 necessarily forced to aim closer to the
6:42 space where the artery is. and the
6:44 smaller and the more involuted the more
6:46 risky that would be. So this means there
6:47 are certain circumstances where the
6:49 claim that the vertical injection is
6:51 more risky might actually be true. Now
6:53 it's not actually a time when I think
6:55 you will actually intuitively use that
6:56 style of injection. I'm sure there are
6:58 some people out there who would but
7:00 mostly when you see these vertical
7:01 injections they are actually on already
7:03 slightly fuller lips trying to get a
7:05 little bit of elevation. Um not so much
7:06 for restoration. Now I'm sure some
7:08 people do but that's not when I would
7:10 use it. But I do believe that's a
7:12 circumstance where a vertical injection
7:14 might be riskier. That's very useful cuz
7:16 now I have an additional level of nuance
7:18 and understanding to my anatomy because
7:20 the anatomy changes and the risk profile
7:22 of different injections might change as
7:24 volume is lost. I actually think this is
7:26 true all over the face because if you
7:28 think about it, arteries will take up a
7:30 relatively bigger percentage of the
7:33 space in the face as volume decreases
7:34 because I don't think your artery
7:35 shrinks as much as your fat pads. So
7:36 it's an interesting way of thinking
7:38 about risk. That's the thing. thing I've
7:40 got most out of this exercise is
7:41 realizing that in certain circumstances
7:43 the risk profile might be different for
7:45 the same injection. So, what do you
7:47 think? Has that improved your mental
7:49 model at all? Have I got it in a way
7:50 that contradicts your mental model? I'd
7:52 love to hear in the comments down below.
7:53 But most of all, I'd love to hear, are
7:55 you a horizontal injector or a vertical
7:57 injector? Let us know in the comments
