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